Exam Retake This form should only be completed if you have failed an exam attempt and need to pay the exam retake fee to access a 2nd or 3rd/final attempt. Do not submit this form or payment for your 1st attempt as that is included in your initial certification fee. Name of Applicant or Certificant* First Last Home Address* City State / Province / Region Email Address* Exam Attempt*1st Attempt2nd Attempt3rd/Final AttemptTotal $0.00 Payment Method*I will pay onlineI will pay by phoneMy employer will pay by phoneCredit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name