Specimen Collector Recertification

Part 1: Company Information
(as printed on renewal form sent to you):
Company Name
Primary Email
if any inforrmation on page 1 of the DATIA renewal form is not accurate, please correct in next section.
Please add current email. Fields in Red are required values.
Corrections and additions to the information on the DATIA Form
Primary Contact Name
Company Name
Address
City
State
Zip
Phone
Fax
Web
Other changes or notes
I agree to abide by all DATIA Certification Rules (as printed document in your renewal envelope)

Part 2: Renewing Collector Recertification Registration
Collector Renewal Exam #1
CP-ID Name
Email (for exam results)
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
Collector Renewal Exam #2
CP-ID Name
Email (for exam results)
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
Collector Renewal Exam #3
CP-ID Name
Email (for exam results)
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
Collector Renewal Exam #4
CP-ID Name
Email (for exam results)
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
Collector Renewal Exam #5
CP-ID Name
Email (for exam results)
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
Part 3: New Collector Registrations
New Collector Exam Registration #1
Name
Email (for exam results)
Process of Exam
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

address same as company? Yes No
only complete if no is checked above
address
phone fax
city
state
zip
I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.
New Collector Exam Registration #2
Name
Email (for exam results)
Process of Exam
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

address same as company? Yes No
only complete if no is checked above
address
phone fax
city
state
zip
I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.
New Collector Exam Registration #3
Name
Email (for exam results)
Process of Exam
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

address same as company? Yes No
only complete if no is checked above
address
phone fax
city
state
zip
I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.
New Collector Exam Registration #4
Name
Email (for exam results)
Process of Exam
Date of most recent mock collections
Name of monitor of mock collections
Monitor Email

* A sampling of certification candidates will be audited annually to ensure that mock collections were performed as required.

address same as company? Yes No
only complete if no is checked above
address
phone fax
city
state
zip
I attest I have successfully completed the DOT required training, inclusive of the five consecutive, error free mock collections.

Part 4: Accredited Collection Facility (ACF) Renewal
If your Renewal form indicates you are currently an Accredited Collection Facility (ACF)
Agree to Accredited Collection Facility Standards of all collectors at my facility are trained and are scheduled above to take exam, or are renewed through June 1, 2014.

Part 5: Totals
To qualify for discounted fees, the minimum number of collectors for the tier must be submitted at one time. Once a tier has been reached, the fee remains in effect for the current certification year. For example, a company that has submitted 22 registrations and hires a new employee one month later may register the single employee at the 16-25 tier rate.

Description

Number

Cost

Amount

1. Recertification Exams for CPC and CPCTs*
2. New Applicant Exams for Cerification Status
3. CPC Manual
4. CPCT Manual

TOTAL

*Pre-calculated at the following tiered discount: 1-5 collectors $95 each; 6-10 $80; 11-15 $65; 16-25 $50; 26+ $35.

Part 6: Payment Information
Payment Type:

MC
VISA
AMEX
Card #
Cardholder's Name
Exp. Date
This is a secure order form but if you prefer to print this out our Fax (202) 315-3579

Check payments should be mailed to DATIA • 1325 G Street, NW, Suites 500-5001 • Washington, DC 20005


REFUND/TRANSFER POLICY: No refunds are offered for DATIA certification exam registrations once payment is submitted. In addition, no transfer of registrants is allowed as the original registered candidates(s) retains access to the exam registration

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