NCCER Registration & Release Form

Instructions

Type or print legibly. Any inaccuracies on this form may be reflected on credentials. To be entered in NCCER's Registry, you must complete and sign this form. Records containing trainee/participant personal information, including but not limited to score reports, training prescriptions, and transcripts, cannot be distributed until this form has been completed.

ATS/AAC Name

Name(Required)

First Last

Job Title

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email Address(Required)

Birth Date(Required)

Birth City

To enter you into the NCCER National Registry, ONE of the following numbers needs to be provided. Once you are entered into the system, you will be given an NCCER Card Number to use in the future. (System Generated Numbers are no longer an option.) Pipeline users MUST use their Social Security Number.

Social Security Number(Required)

NCCER Card Number

State DOE Student Number

Which State?

State

If you choose to use the State DOE Student number, this must first be added into the NCCER Registry System as an approved "Alternate I.D. Type." Please work with your sponsor representative to ensure your state I.D. Type has been added into the system.

Company/School Name

Company/School Address

Street Address City State ZIP Code

I hereby authorize NCCER to verify information in my training and/or assessment records, which may include any of the personal information provided on this form. I release and hold harmless NCCER for the disclosure of any such information in connection with this verification process.

Signature(Required)

Date

Parent/Guardian Signature

(Required if individual is under 18 years of age)

Date