Certification Exam Registration & Payment Form

1. Personal
Dr. Esq. Jr. Sr. Miss Mr. Mrs. Ms.

Title/Salutation: Given name: Middle name: Last name (surname): Suffix: II III

Email Address:

Use an email address you check regularly. This is the email address we will use to contact you. Secondary E-mail Address:

If any information has changed since you submitted your application, please indicate the change here:

2. Examination Registration
I am registering for the following exam: Certification of Competency in Business Analysis (CCBA) Exam Certified Business Analysis Professional (CBAP) Exam Enter the location and date of the certification exam that you are interested in taking. The list of computer-based testing (CBT) centers and the list of paper-based scheduled exams may be found on the IIBA Web site. Exam location: Exam date (if known):

To ensure equal opportunities for all qualified persons, IIBA will make reasonable accommodations for candidates when appropriate. Do you have special needs which may impair your ability to take the certification exam? No Yes. Please complete the information below. You are also required to provide the written documentations from an appropriate Health Care Professional to support the need for the accommodation. This documentation must include a diagnosis of your health condition and a

specific recommendation for the type of special accommodations you will require. Failure to include supporting medical documentation will cause a delay in processing your application. IIBA does not pay any costs you may incur in obtaining this information. Please identify the disability that significantly impairs your ability to arrive at, read or write the exam, or any other related skills required to complete the examination:

Please list the special accommodation requested.

Payment Information:
Identify exam attempt: First attempt ($325.00 USD for IIBA members or $450.00 USD for non-members, plus GST/HST for Canadian residents) Second attempt ($250.00 USD for IIBA members or $375.00 USD for non-members, plus GST/HST for Canadian residents) I have included my exam fee with this form. Yes

I understand the following: This examination/application is the property of International Institute of Business Analysis. This examination/application is confidential and is protected by copyright. No part of this examination/application may be reproduced, copied, memorized, taken out of the examination room, divulged or disclosed to anyone. I understand that I may not discuss or disclose the contents of this examination orally, in writing, by any digital, electronic or by other means. Printed name: Date:

Signature: __________________________________