NACM Brochures 2017 NACM Professional Certification Program - Page 9

Application for the Credit Business Associate SM (CBA SM ) Designation Applicant Information Mr./Ms. First Name Middle or Maiden Name Title Last Name Business Email Address Company Business Mailing Address City State/Province Zip/Postal Code Country City State/ Province Zip/Postal Code Country Direct Business Telephone Main Business Telephone Zip/Postal Code Country Business Shipping Address Home Address City State/ Province Home Telephone Personal Email Address Birth Month/Day (MM/DD) __________ The name of my local NACM Affiliated Association: _______________________________________ I understand that I must already be registered with the National Education Department. (If you are not already registered, please attach a registration form, with the appropriate fee, to this form.) I understand that a non-refundable fee must accompany this application. This fee covers the CBA designation process. I further understand that should I fail to complete this process by not taking the exam within one year of my written approval, I will need to reapply. The application fee is not divisible; no part will be refunded should I not complete the process. Application Fee:   q Member: $235   q Non-member: $335 q A check, made payable to NACM-National Education Department, is attached. Charge to: q VISA q MasterCard q American Express q Card Number Card Security Code Cardholder’s Name Cardholder’s Signature Expiration Date Credit Card Billing Address Please send all correspondence related to this application to: q Home address q Business address I plan to sit for the CBA exam on the following date: q March 5, 2018 (Paperwork Deadline: January 26) q June 10, 2018 – Exam given at NACM’s Credit Congress in Phoenix, AZ only (Paperwork Deadline: April 20) q July 23, 2018 (Paperwork Deadline: June 1) q November 5, 2018 (Paperwork Deadline: September 14) 9