Revised 8/29/14 Valid 9/1/14 8/31/15

NOTE: Please email a photo for your ID card to certification@csia.org.

EXAM: CSIA Certified Chimney Sweep CSIA Certified Dryer Exhaust Technician FORMAT: ONLINE - Please allow 5 business days. PAPER - Please allow 10 business days. Exam Date __________________________________ Exam Time _____________________________________________

CANDIDATE INFORMATION Name ______________________________________________________________________________________ Company Name _____________________________________________________________________________ Address ____________________________________________________________________________________ City, State ZIP _______________________________________________________________________________ Phone ____________________________________ Email __________________________________________ PROCTOR INFORMATION Name ______________________________________________________________________________________ Company Name _____________________________________________________________________________ Mailing Address _____________________________________________________________________________ City, State ZIP _______________________________________________________________________________ Phone ____________________________________ Email __________________________________________

CSIA Certified Chimney Sweep Exams Standard NCSG Member SUB

TOTALCertification Exams Rate includes both exams $479 $279 RETEST - After 14 days and within 12 months of failure.

RETEST ONLY - Successful Chimney Sweeping (SCS) $80 $80 RETEST ONLY - International Residential Code (IRC) $80 $80 RETEST ONLY - SCS and IRC Retest (Both Exams) $110 $110

CSIA Certified Dryer Exhaust Technician Exam Standard NCSG Member SUB

TOTALCertification Exam $379 $179 RETEST (After 14 days and within 12 months of failure.) $80 $80

STUDY MATERIALS Standard NCSG Member SUB

TOTALCOMPLETE CCS 3-BOOK STUDY SET Save $60! includes shipping

1. Successful Chimney Sweeping (2011 edition) 2. NFPA 211 (2013 edition) 3. International Residential Code (2006 edition)

$412 $272

STUDY MATERIALS Al a Carte (does not include shipping) Successful Chimney Sweeping (2011 edition) $330 $180 NFPA 211 (2013 edition) $50 $50 International Residential Code (2006 edition) $89 $89 CSIA Certified Dryer Exhaust Technician Manual (2013 edition) $115 $65

Shipping for Al a Carte Manuals $13 $13 Indiana Residents Add 7% Sales Tax (Materials and Shipping)

TOTAL DUE $ PAYMENT INFORMATION Visa MasterCard American Express Personal or Company Check Credit Card # _____________________________________________________________________________________________Card Security Code: __________________________________Exp. Date: __________________________________________Name on Card: ______________________________________Signature:____________________________________________

PROCTORED EXAM REQUEST

Phone: (317) 837-5362 Fax: (317) 837-5365

REFUND POLICY: If a registrant withdraws from the exam 10 days prior to the exam date, a refund will be issued less a $50 administration fee. If a registrant withdraws after the exam has been processed, no refund will be issued.

For Office Use O2C C2F 2C2R AUTH: ____________________________________COID: ____________PROFID: ______________RECD BY: ________ RECD DATE: ________