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

Part 2: Renewing Collector Recertification Registration
Collector Renewal Exam #1
CP-ID Name
Email (for exam results)
Date of previous 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 previous 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 previous 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 previous 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 previous 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 previous 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 previous 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 previous 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 previous 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: 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

Description

Number

Cost

Amount

1. Recertification Exams for CPC and CPCTs*
2. New Applicant Exams for CPC Certification 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
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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