EXAM REGISTRATION FORM

CONFIDENTIAL WHEN FILLED

Title:
Family name/Surname:
First name/Given:
Address:
City and Postal Code:
Year of Birth:
Home Phone:
Employer:
Job Title:
Business Address:
City and Postal Code:
Business Email:
Highest academic
degree obtained:
How do you want to be
contacted by us?

Other:
Middle Initial:
State/Country
Personal Email:
Home Fax:
Industry type:
State/Country:
Business Phone:

Home Phone

Home Email

Have you taken any PECB exam before?

No | Yes

Business Email

Business Phone

If yes, please write your examination number: ______________

Exam name that youre enquiring about:

If you have a physical or other disability that may require special arrangements, please describe it below:
Please also refer to the Examination Rules and Policies for our complete policy on special arrangements

Examination preferences
Please see the Exam Schedules page at www.pecb.com for a current list of exam dates and locations. Our exams
are available in different languages. Please check our website (www.pecb.com) for availability of your desired
exam language.

Exam Date: ___________________

(YYYY/MM/DD)

Exam location: ___________________________

I HAVE READ AND UNDERSTAND PECB RULES AND POLICIES REGARDING EXAMINATION AND I INTENT TO BE
BOUND BY THEM
Authorized signature:___________________

PECB-404 Exam registration form v1.2

Date and location: ____________________________

PECB
6683 Jean Talon East, Suite 336
Montreal, H1S 0A5, QC
CANADA

PECB-404 Exam registration form v1.2

Filled form must be send to PECB Examination via email at:

examination@pecb.com