CSCIP Certification Training, Documentation, and Exam REGISTRATION and ORDER FORM

Updated August 2010

CSCIP/INTERNATIONAL

CERTIFIED SMART CARD INDUSTRY PROFESSIONAL

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

(All applicants must complete the CSCIP application form and be approved by the CSCIP certification committeebefore ordering the CSCIP training documentation or registering for training)

CSCIP Member Number:(not required)
Approved CSCIP member since: / Are you a LEAP member? Yes: No:
(1st year LEAP membership is included in training course registration for International members only)
Name: / Title:
Company: / Country:
Mailing address:
Telephone number: / E-Mail:
Number of years with current company:

Check all that apply to this order form

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

I wish to order the CSCIP/International Smart Card Technology and Applications Training Modules

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

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

I DO NOT wish to register for the CSCIP/G Training Course and Exam* at this time (I will register at a later date)

CSCIP/InternationalTraining & Exam Prep Course and Certification Exam Location (listed on LEAP web site)

City: / Country:
CSCIP/Int’lTraining & Exam Prep Course Date: / CSCIP/Int’l Exam Date:

Please check the boxes of the items you wish to order with this form:

CSCIP/International Smart Card Technology and Applications Training Course Modules: $100.00*

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

CSCIP/International Smart Card Technology and Applications Training Course + Hardcopy version:$175.00*+

$25 shipping = $200.00*(This option includes the electronic version plus a hardcopy printed version inbinder)

CSCIP/InternationalTraining & Exam Prep Course**and Exam Fee(Includes 1st year LEAP membership fee)

Registration fee: $850.00Registration fee for Smart Card Alliance Members (20% discount): $680.00

CSCIP/International Exam re-takefee: $ 100.00 (Select this only if you are registering to retake CSCIP exam)

Enter total amount to be charged to the credit card below: $

* All applicants must purchase the CSCIP/International Smart Card Technology and Applications Training Course

Modules in order to register for the CSCIP/International certification training course and exam

**TheCSCIP/InternationalTraining and Exam Preparation Courseis offered by the Smart Card Alliance one (or

more) days prior to the scheduled CSCIP/Icertification exam. This 1 day course is conducted by a Smart Card

Alliance Professional Certification Trainerwho will provide instruction based on the CSCIP/International training

course modules and review key points that will be covered in the CSCIP/International exam.

The Smart Card Alliance accepts credit cards and international wire transfers as payment in U.S. dollars

(For international wire transfer instructions please send your request to )

Wire Transfer: International wire transfers: Bank of America 3745 Quakerbridge Road Mercerville, NJ USA 08619

(1)609-586-8200 International SWIFT # BOFAUS3N, SCA Bank Account # 381 018 973 631 US currency only.

Payable to: Smart Card Alliance, 191 Clarksville Road, Princeton Junction, New Jersey USA08550)

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

Name on the Card:
Billing Address, City, State, :
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