ERSEA Certification Exam 90-102 Enrollment

HS University

Exam 90-102 Enrollment Form

Required Items. Please read the cancellation policies.

Student Information: Only one student per form.

Certification Program #:

Student ID: :

Student Full Name:

Student Email:

Student Job Title:

Student Phone:

Student Fax:

Student Address:

Student Mailing Address:

Student City:

Student State:

Zip:

Agency Information:

* Agency:

* Phone:

Fax:

Billing Address:

City:

State:

Zip:

Course Information:

* Exam:

Other Location::

Exam Cost:

$185.00 per person

Please choose an alternate exam. Read the cancellation policies.

Alternate Exam Date::

Payment Method: NOTE: All exams must be paid in full for on or before Deadline listed above. Students that have not paid exam on or before deadline will not be allowed to take examination on exam dates. Checks and POs must be cleared before deadline date. Once payment is received, students will be contacted with online examination information, i.e. times and login information.
* Payment Method:	PO#:
	Please bill the company: letter of authorization or purchase order will be faxed to (901) 758-4036. I have read and understand the cancellation policies for HSU courses.
Card No:
Expiration Date:
Security Code:	(3-digit security code on back of card)
Name on Card:
Authorizing Manager:
Comments:
Payment Method:

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HSU provides a range of services to allow persons with disabilities to participate fully in educational programs and activities. If you desire support services, contact the student Access Center at (901) 758-4034.

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