| SECTION I: APPLICANT INFORMATION | SECTION IV: EXAMINATION INFORMATION |
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1. Name: (Last, First, M.I.) 2. RANK: 
3. SSN:
4. DOB: (MM/DD/YY)
5. Unit Assignment:
6. If Active Duty, but NOT AGR or TAR: (choose one) 0 Army 0 Navy 0 Air Force 0 Marine Corps 0 Coast Guard 0 Not Applicable 7. If AGR (Active Guard Reserve) or TAR: (choose one) 0 Army 0 Navy 0 Air Force 0 Marine Corps 0 Coast Guard 0 Not Applicable 8. If Reserve Component: (but not Active,AGR or TAR) (choose one) O Army National Guard O Air National Guard O Army O Navy O Air Force O Marine Corps O Coast Guard O Not Applicable SECTION II: ADDRESSES
1. Upon receipt of test score report, provide address to which check will be sent. ___________________________________________ ___________________________________________ ___________________________________________ _____________________Zip Code_________-______ Day Time Phone: 0 DSN 0 CML ( ) _________
2. Education center name and address: SECTION III: NATIONAL ASSOCIATION
Name and address of National Association: ____________________________________________ ____________________________________________ ____________________________________________ ____________________Zip Code_________-______ Phone: 0 DSN 0 CML ( ) ________-____________ |
1. Type of examination taken: ___________________________________________ ____________________________________________ ____________________________________________ 2. Date administered: (MM/DD/YY) ________________________________________________________ 3. Cost of examination:
guides, processing fees, etc., WILL NOT BE REIMBURSED. 4. Attach copies of your method of payment (check or money order) and a copy of your ORIGINAL test score report. SECTION V: CERTIFICATION
Student I certify that I sat for the above test and request reimbursement for the cost of the exam. Signature:_________________________________________ Date: (MM/DD/YY) __________________________________ Duty Phone: O DSN O CML ( )______-_______________ Official I certify that I am the Test Control Officer (TCO) or Alternate TCO and that the above student was counseled and determined eligible to sit for the stated certification examination. Please process for reimbursement. Signature:_________________________________________ Date: (MM/DD/YY) __________________________________ Duty Phone: O DSN O CML ( )______-_______________ DANTES ID NUMBER: [ ] [ ] [ ] [ ] |
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Distribution: White copy: Send with copy of test score report to DANTES, Code 20J, for purpose of reimbursement. Pink copy: DANTES Test Center file copy. Yellow copy: Students's copy. Important: Read the Privacy Act Statement on the reverse side of this form.
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Data Required by the Privacy Act of 1974 (5 U.S.C. 552a) Authority: 5 U.S.C. 301 |
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NOTE: This Privacy Act Statement applies to all information on this form. Your signature in Section V authorizes DANTES to receive an official copy of test score report containing information on your pass or fail test completion and your issuance of a certificate. a. PURPOSE: To facilitate completion of certification examination listed in the DANTES Examination Program Handbook, DANTES National Calendar of Certification Tests, or Be A Certified Professional (brochure). b. ROUTINE USE: Use of the Social Security Number is necessary to make positive identification of an individual's record. c. MANDATORY OR VOLUNTARY DISCLOSURE AND RESULT OF FAILURE TO PROVIDE INFORMATION: Disclosure of all information, including Social Security Number is voluntary. Failure to provide all information listed on form will complicate, delay, or possibly prevent the administrative actions necessary for payment on a professional certifying examination listed in the DANTES Examination Program Handbook, DANTES National Calendar of Certification Tests, or Be a Certified Professional (brochure).
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