Re-Certification Request Form

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American Traffic Safety Services Association
15 Riverside Parkway, Suite 100, Fredericksburg, VA 22406-1022
Toll Free 1-877-642-4637
(540) 368-1711 Fax: (540) 368-1722
RE-CERTIFICATION REQUEST FORM
Flagger Instructor
ATSSA Member $109_____
Non-Member $130 ____
Pavement Marking Technician
ATSSA Member $109 _____
Non-Member $130 ____
Traffic Control Supervisor
ATSSA Member $109 _____
Non-Member $130 ____
Traffic Control Supervisor On-Line Re-Cert Make-up
ATSSA Member $25 _____
Non-Member $25 ____
Traffic Control Technician
ATSSA Member $109 _____
Non-Member $130 ____
Flagger Re-Registration (On-line or Proctored only)
ATSSA Member $25 _____
Non-Member $35 ____
Traffic Control Design Specialist (unavailable on-line)
ATSSA Member $109 _____
Non-Member $130 ____
RE-CERTIFICATION OPTIONS
________________
TAKE EXAM ON-LINE Date:
On-Line exams will be an additional $35.00.
If taking the on-line exam you must provide us with a current email address.
________________
TAKE EXAM AT AN ATSSA COURSE Course Location:__________________ Date:
You need to be present for the exam on the last day of the course. If you need a course schedule, please call ATSSA.
½
ATTEND A FULL COURSE AS A REFRESHER AT
PRICE
Course Location:_______________Date:__________
(You will be charged the re-certification fee plus ½ of the course fee if you choose this option.)
_______________________________
I WANT THE EXAM PROCTORED
Exam Date:
It is your responsibility to obtain the proctor. The proctor may be:
a professional educator (teacher, principal, etc.) with current teaching credentials
a public official at department head level
a city, county or state staff person (human resources manager or training officer)
The proctor selected cannot be a person with whom you have a direct working relationship. You and the proctor will
determine the exam date. ATSSA needs to receive this completed form within 10 working days your scheduled exam
date to guarantee that your study materials or the test will reach the intended destination in a timely manner.
PROCTOR________________________________________________
TITLE____________________________ __
COMPANY / AGENCY / SCHOOL:__________________________________________________________________________________
SHIPPING ADDRESS:_____________________________________________________________________________________________
CITY / STATE / ZIP:_______________________________________________________________________________________________
PHONE:
FAX:____________________________________________________
____Mr. ___ Ms. First Name______________________________MI______ Last Name________________________________________
Title/Position:___________________________________________
Company Name:__________________________________________
Shipping Address___________________________________________________________________________________________________
City: ____________________________________________
State:__________________
Zip:_________________________
Company Phone: (
) ____________________ FAX: (
) __________________E-Mail_________________________________
Payment Method
_______Check (payable to ATSSA)
PO#____________________________________
(Allowed for Govt. Agencies Only. Copy of purchase order
required at time of registration)
Charge my: _______Visa
_______M/C
_______AMEX
Account #_________________________________________________Card Holder:____________________________________________
Expiration Date:________________________ Authorized Signature:________________________________________________________

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