SECTION I: APPLICANT INFORMATION SECTION IV: EXAMINATION INFORMATION

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:

Zip Code -

Phone: 0 DSN 0 CML ( ) -

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:

Note: Registration fees, preparationguides, processing fees, etc.,WILL NOT BE REIMBURSED.

4. Attach copies of your method of payment (check or moneyorder) 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: [ ] [ ] [ ] [ ]

Distribution: White copy: Send with copy of test score report to DANTES, Code 20J, for purpose of reimbursement. Pink copy: DANTESTestCenterfile copy. Yellow copy: Students's copy.

Important: Read the Privacy Act Statement on the reverse side of this form.

DANTES Funded Certification Examination Form For Service Members

Data Required by the Privacy Act of 1974 (5 U.S.C. 552a) Authority: 5U.S.C. 301

NOTE: This Privacy Act Statement applies to all information on this form. Yoursignature in Section V authorizes DANTES to receive an official copy of test scorereport containing information on your pass or fail test completion and your issuance of acertificate.

a. PURPOSE: To facilitate completion of certification examination listed in theDANTES Examination Program Handbook, DANTES National Calendar ofCertification Tests, or Be A Certified Professional (brochure).

b. ROUTINE USE: Use of the Social Security Number is necessary to make positiveidentification of an individual's record.

c. MANDATORY OR VOLUNTARY DISCLOSURE AND RESULT OFFAILURE TO PROVIDE INFORMATION: Disclosure of all information, includingSocial Security Number is voluntary. Failure to provide all information listed on formwill complicate, delay, or possibly prevent the administrative actions necessary forpayment on a professional certifying examination listed in the DANTES ExaminationProgram Handbook, DANTES National Calendar of Certification Tests, or Be aCertified Professional (brochure).

This form may be ordered from DANTES by using stock number 2309 on the DANTES Material Request Form. Send the Material RequestForm to Defense Activity for Non-Traditional Education Support, Code 30J, 6490 Saufley Field Row, Pensacola FL 32509-5243.

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DANTES 1562/31 (Revised 10/97). Previous versions obsolete.