Name (as to appear on certificate)
Address (for mailing certificate)
Address Line 2
State / Province / Region
ZIP / Postal Code
Expected Date of Test
MM slash DD slash YYYY
Location of Test
(ex. Henderson Public Library, NV)
Which Test Are You Taking?
Name of current Green Belt or equivalent certification
Organization who provided the certification
I have read the AALSSC code of conduct and agree to terms
I agree not to disclose the content of examination to any third party
I affirm all the information included is true and accurate
I affirm the test proctor does not have a conflict of interest
I understand AALSSC is permitted to disclose to the general public the status of my certification. All other information is treated as confidential and will only be released with written permission.
As provided for under the ADA (Americans with Disabilities Act), do you require special needs accommodations in order to complete the certification process?
Please describe your circumstance
Digital Signature by Typing Your Name