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NECC TEST SITE APPLICATION

 

NAME OF AGENCY 

        Business Phone     Business Fax

 

Type of Agency     Number of Employees   Web Site Address

Type of Internet Connection      

 

PHYSICAL ADDRESS

Address Line 1

Address Line 2

City    State or Province   COUNTRY       Postal Code / Zip

 

MAILING ADDRESS (IF DIFFERENT)

Address Line 1

Address Line 2

City     State or Province    COUNTRY     Postal Code / Zip

 

AGENCY PROCTOR

Name of Assigned Agency Proctor     Title

Phone     E-Mail

Best time & method to reach Proctor

 

EXAM SITE MANAGER

Name      Title     Phone     E-Mail

 

Do you plan to charge candidates a testing fee?     If so, how much?

 

Comments

 

NECC EXAM SITE APPLICATION SIGNATURE

I have read and understand the information concerning roles, responsibilities and requirements pertaining to being an NECC test site and attest to meeting or exceeding those requirements and responsibilities. (click here for copy)

I certify that the above information is true to the best of my knowledge as of the date indicated below and that I am authorized to sign this agreement on behalf of this agency.  Unless otherwise indicated this agreement is for all candidates in this area for one year.  Either party may end this agreement at any time.

Name of person submitting this application on behalf of Agency

Title of person submitting application Phone

Date