HA: Provider Application

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Billing Info:

First Name:

Last Name:

Title:

Street Address:		Order

City:

Country:

State/Province:

Zip/Postal Code:

Telephone:

Email Address:

Billing Center

Billing Preferences:

NABCEP invoices Registered Providers for:

Annual fees ($300.00/yr.)
Paper & Pencil Exams ($125/candidate)
CBT authorizations ($125/candidate)
Miscellaneous administration fees (see Exam Administrator Manual)

NABCEP prefers to send invoices via email. Please indicate preference:

Paper / Postal Mail

Billing Right

Application Payment:

How would you like to pay the $300.00 application fee:

Payment:

N/A

Pay Now

Pay Later

Pay Now: secure online payment by check or credit card
Pay Later: we'll invoice your organization but your application will not be reviewed until payment is received

Field Progress:

Each "step" or page of the form has x fields on it. We need to determine, for each step, how many of the fields have been filled out.

Exam Type: *

Leave this field blank:

IMPORTANT:

Please thoroughly review the Associate Provider Info Packet before completing your application.

Phone:	(800) 654-0021
Fax:	(518) 899-1092
Hours:	9am-5pm (EST) M-F
Email:	info@nabcep.org