(This request form is for the 2018 verifier written re-certification).

* The fee per examination is $49.00 dollars. This must be prepaid. Please
make check payable to NITC. Visa, Master Card or American Express is also accepted. The
method of payment must be attached at the time of submission or contact NITC to provide
credit card payment information by phone at (877) 457-6482. For NITC No-Show, Cancellation
and Refund Policy refer to the Candidate Bulletin.

*This request form must be submitted no later than (3) weeks prior to
examination date. Please e-mail medgascerts@nationalitc.com.

*All exams will be administered via computer.

*A minimum of 10 examinees is required for an examination. If there are less than 10 examinees,
a processing fee of $150.00 will be applied.