DATIA New Certification Application

Part 1: Company Information
Company Name
Primary Contact Name
Primary Email
Address
City
State
Zip
Phone
Fax
Web
Notes
I agree to abide by all DATIA Certification Rules
Part 2: New Collector Registrations
New Collector Exam Registration #1
Name
Email (for exam results)

*Note: Exams are currently only available online

Date of most recent mock collections
Name of monitor of mock collections
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)

*Note: Exams are currently only available online

Date of most recent mock collections
Name of monitor of mock collections
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)

*Note: Exams are currently only available online

Date of most recent mock collections
Name of monitor of mock collections
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)

*Note: Exams are currently only available online

Date of most recent mock collections
Name of monitor of mock collections
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 3: Accredited Collection Facility (ACF)
If you wish to apply as an Accredited Collection Facility (ACF)
I represent that all collectors at my facility are trained and are scheduled above to take exam.
Part 4: Tiered Rate - OPTIONAL
We have met the minimum number of collectors in THIS exam year to qualify for a tiered rate.
    = $ each

6-10 = $80 each
11-15 = $65 each
16-25 = $50 each
26+ = $35 each
The totals as listed below will NOT be applied to your credit card, if indeed your company has met a different tiered price this year, and they will be adjusted prior to processing.
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

New Applicant Exams for Certification Status
CPC Manual
CPCT Manual

TOTAL

Part 6: Payment Information
Promo Code:
Enter your promo code here. Discounts based on your promo code
will be applied before payment is processed.
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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