Application - AALSSC

Name (as to appear on certificate)*

*First (required) Middle *Last (required) Suffix

Address (for mailing certificate)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Expected Date of Test*

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

Proctor Name*

Proctor Title*

Proctor Email*

Acknowledgements*

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*