Certified Smart Card Industry Professional

Updated April 2012

CSCIP/PAYMENTS

CERTIFIED SMART CARD INDUSTRY PROFESSIONAL

CSCIP/P Certification Training, Documentation, and Exam REGISTRATION AND ORDER FORM

(All applicants must be LEAP members AND approved CSCIP members at the time of registration)

LEAP Member Number:
(leave blank if not available) / LEAP member since:
Approved CSCIP member since:
Name: / Title:
Company: / Country:
Mailing address:
Telephone number: / E-Mail:
Number of years with current company:

I have read the LEAP/CSCIP terms and conditions manual and understand the requirements for the program

I wish to register for the CSCIP/P Exam* (Enter the city, state, country, and date in box below)

I wish to register for the optional CSCIP/P Training and Exam Prep Course

I do not wish to register for the CSCIP/P Training Course or Exam* at this time and will purchase materials only (you may register for the course/exam at a later date)

CSCIP Training & Exam Prep Course and CSCIP Certification Exam Location (from LEAP web site)

City: / State/Prov: / Country:
CSCIP/P Training & Exam Prep Course Date: / CSCIP/P Exam Date:

Please check the boxes of the items you wish to order:

CSCIP/Payments Certification Exam Registration fee: $150.00*

CSCIP/P Smart Card Technology and Applications Training Course Modules (8 modules): $100.00*

(This option is for an electronic version that can be viewed, saved to a desktop, and printed as needed)

CSCIP/P Smart Card Technology and Applications Training Course + Hardcopy version (8 modules):

$175.00* + $10 shipping = $185.00*

(This option includes the electronic version plus a hardcopy printed version in a 3 ring binder)

CSCIP/PTraining & Exam Prep Course**

Registration fee: $475.00 SCA Members (20% discount): $380.00

Enter total amount to be paid by check or charged to the credit card below: $

* All applicants must purchase the CSCIP/P Smart Card Technology and Applications Training Course Modules in order to register for the CSCIP/P certification exam

**An optional CSCIP/Payments Training and Exam Preparation Course may be offered by the Smart Card Alliance prior to the scheduled CSCIP/P certification exam. This 1 day course is conducted by a Smart Card Alliance Professional Certification Trainer who will provide instruction based on the CSCIP/P training course modules and explain key points that will be covered in the CSCIP/P exam.

The Smart Card Alliance accepts checks and credit cards as payment for CSCIP orders

Check (Please note “LEAP” on the memo line of the check, which must be drawn in US currency only.

Payable to: LEAP Department, Smart Card Alliance, 191 Clarksville Road, Princeton Junction, NJ08550)

Credit card: Visa, MasterCard, American Express, Discover Card, and JCB are accepted.

Name on the Card:
Billing Address:
Card Number: / Country:
Expiration Date: / Security Code:

Fax completed form to: 1-609-587-4248

For questions, call 1-800-556-6828 or email us at