SECURE PAYMENT FORM

 

International Board for Certification of
Safety Managers

CHSP

CHSP-FSM

CPSO

CPSM

CHEP

CHEP-FSM

CEDP

CHS-LTC

CHCM

CHCM-SEC

CHSN

CHS-EVS


(New Applicants) INCLUDE FULL NAME:

(Members) INCLUDE NAME/CERT #'s

 


2016 Annual Dues 
(Active Members)

Late FeePayments

Made After 12/31/2015

2016 Annual Dues  

(Retired Members)

CHSP $125.00 CHSP $25.00

CHSP $45.00

CHCM$125.00 CHCM $25.00

CHCM $45.00

CHEP $125.00 CHEP $25.00 CHEP $45.00
CPSM $125.00 CPSM $25.00  CPSM $45.00
CPSO $125.00 CPSO $25.00 CPSO $45.00
CEDP $125.00 CEDP $25.00 CEDP $45.00
CHSN $125.00 CHSN $25.00 CHSN $45.00
CHS-LTC $125.00 CHS-LTC $25.00 CHS-LTC $45.00

CHS-EVS $125.00 

CHS-EVS $25.00

CHS-EVS $45.00

 

CHSP-FSM $75.00

 

CHSP-FSM $45.00

CHEP-FSM $75.00

 

CHEP-FSM $45.00

Back dues amount below is per certification.

2013 Back Dues $125.00

2014 Back Dues $125.00

2015 Back Dues $125.00

Total Amount Of Back Dues:

 

Other Fees

5 Year Re-Certification Fee: $85.00

Application Fee: $130.00

Exam Fee: $200.00

International Application Fee: $150.00

International Exam Fee: $200.00

Hand Stamp: $80.00

Pocket Seal: $95.00

Wallet Card Replacement: $20.00

Wall Certificate Replacement: $35.00

Replacement Fee Exam Book: $10.00

 

 

Please List Any Other Fees &  Amounts Not Listed Above:

 

Credit Card Information:  

ALL FIELDS REQUIRED

 

FILL IN PURCHASE AMOUNT BELOW!

 

Card Type:

Name as on Card:

Card Billing Zipcode:

Purchase Amount:

Card Number:

Card Expiration Date:

MMYY

Card ID (CVV2/CID) Number:
 [What is the Card ID?]

 

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