CAPM Certification Application

PAGE 1 OF 6 | YOUR INFORMATION

Tips for completing this form:: Hand-write your information clearly in blue or black ink onto a printed form and submit it by postal mail. Type your information into the PDF. If you have PDF-editing software, you can save your data. Otherwise, you will only be able to type your information, then, print out the form and send to PMI. All information and documentation must be in English. Faxed or scanned copies will not be accepted. PMI Member ID#: If you are a member of PMI you have an ID number. Your ID number is on the membership card you received in your welcome kit when you joined. If youve lost your PMI member ID number you may contact PMI Customer Care at +1-610-356-4600, or send e-mail to [email protected].

Instructions: In this section you are being asked to PRINT your name for three separate purposes. It is very important that you complete this section carefully. Section 1. Please print your name as you wish to be referred to in correspondence from PMI. Section 2. Please print your name as it appears on your government-issued identification that you will present at the testing center. Section 3. Please print your name as you wish it to appear on your CAPM certificate. Section 1. Name for correspondence from PMI: Prefix (Mr., Mrs., Ms., Dr.): First Name (given name): Middle Name: Suffix:

Last Name (family name, surname). Candidates with only a single name should use last name field:

Section 2. Name on government-issued identification: Prefix (Mr., Mrs., Ms., Dr.): First Name (given name):

Check here if same as above.

Middle Name: Suffix:

Last Name (family name, surname). Candidates with only a single name should use last name field:

Section 3. Name for your CAPM certificate: Prefix (Mr., Mrs., Ms., Dr.):

Check here if same as above.

Middle Name: Suffix:

First Name (given name):

Last Name (family name, surname). Candidates with only a single name should use last name field:

Prefered Mailing Address: Home Address:

Home Business
City: Country:

Billing Address*:

Home Business

*If paying by credit card, your billing address must match the address on your credit card statement.

State/Province/Territory: Zip/Postal Code:

Business Address:

Business Name: City: Country: State/Province/Territory: Zip/Postal Code:

PRA-231-2011(01-12)

YOUR INFORMATION | EXPERIENCE VERIFICATION | EDUCATION | GENERAL INFORMATION | PAYMENT

CAPM Certification Application

PAGE 2 OF 6 | YOUR INFORMATION (Continued)
Preferred E-mail: E-mail:

Personal Work

Preferred Phone: Phone:

Home Business Mobile

Extension:

Preferred Fax: Fax:

Home Business

Applicants Primary Industry:

Aerospace Automotive Business Communications

Construction Consulting Education Engineering

Finance Healthcare Human Resources Information Technology

Manufacturing Pharmaceuticals Telecommunications Other: ___________________________

Highest level of education attained at the time of this application:

High School Diploma / Global Equivalent Associates Degree / Global Equivalent

Year diploma/degree was awarded: Address:

Bachelors Degree / Global Equivalent Masters Degree / Global Equivalent

Name of High School, College or University: City: Country:

Doctoral / Global Equivalent

State/Province/Territory: Zip/Postal Code:

Field of Study:

Communications Computer Science Education

Engineering Finance Liberal Arts

Marketing Mathematics Pharmaceuticals

Science Other ___________________________

YOUR INFORMATION | EXPERIENCE VERIFICATION | EDUCATION | GENERAL INFORMATION | PAYMENT

CAPM Certification Application

PAGE 3 OF 6 | EXPERIENCE VERIFICATION
Use the Experience Verification form to document at least 1,500 hours of project team experience. Alternatively, you may skip this section and document 23 contact hours of project management education/training on the Project Management Education Form. Number your projects and submit one set of Experience Verification Forms per project. Please photocopy these forms if you require additional space. Project #: Project Title: Project Role: Job Title: Organization Address: City: Country: Phone (Country Code, Area/State/City Code, Phone Number): Extension: Start Date (MM/YYYY): Project Industry: Organization Name: State/Province/Territory: Zip/Postal Code: Completion Date (MM/YYYY):

Please identify and provide current information for your primary contact on this project so that PMI can verify your professional work experience. First Name (given name): Last Name (family name, surname):

Contact Relationship:

Project Sponsor Manager/Director Client Primary Stakeholder

Extension: E-mail:

Phone (Country Code, Area/State/City Code, Phone Number):

Total the number of hours you applied to each project management process group during your project team experience. (A total number of 1,500 hours is needed to meet the eligibility requirement). Then, by process, summarize your project team experience in the spaces provided below. Please ensure your description is between 50-80 words (300-500 characters). Initiating Processes:

Planning Processes:

Executing Processes:

Controlling Processes:

Closing Processes:

Total Hours for Project:

YOUR INFORMATION | EXPERIENCE VERIFICATION | EDUCATION | GENERAL INFORMATION | PAYMENT

CAPM Certification Application

PAGE 4 OF 6 | EDUCATION
You are only required to complete this form if you have not documented 1,500 hours of project team experience. Please copy this form if you require additional space. Please document 23 contact hours of project management education/training that will be completed prior to sitting for your examination. One contact hour is equal to one hour of participation in an educational activity. These hours must be related to project management and can include content on project quality, scope, time, cost, human resources, communications, risk, procurement, or integration management. Courses, workshops and training sessions offered by one or more of the following education providers apply.

A. B. C. D. E. F.

PMI Registered Education Providers (R.E.P.s)* - University/college academic and continuing education programs PMI chapter and community* Employer/company-sponsored programs Training companies or consultants Distance-learning companies,including an end of course assessment University/college academic and continuing education programs

The following education does not satisfy the education requirements:

PMI chapter meetings Self-study (e.g., reading books)

*Courses offered by PMI R.E.P.s, PMI chapters and communities of practice, or PMI, are preapproved for contact hours in fulfillment of eligibility requirements.

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

YOUR INFORMATION | EXPERIENCE VERIFICATION | EDUCATION | GENERAL INFORMATION | PAYMENT

CAPM Certification Application

PAGE 5 OF 6 | GENERAL INFORMATION
Please include me in:

Communications from PMI regarding its products, events and services

Third Party Mailing Lists Mailings Mailings from organizations other than PMI

OPTIONAL INFORMATION
The following questions are optional, and you may choose not to answer them. Reason you are applying for this certification:

Employer Required Yes No

Employer Suggested

Personal Development

Have you taken a certification preparation course presented by a PMI Chapter?

Have you taken PMIs Applying the Fundamentals of Project Management?

Yes No
SPECIAL ACCOMODATIONS FOR EXAMINATION

Check here if you have special needs which may impair your ability to take the examination. Please complete the Special Accommodations Form. The completed form and supporting medical documentation must be returned to PMI along with your completed credential application.

LANGUAGE AID FOR EXAMINATION

All PMI credential examinations are administered in English, but assistance can be provided with an accompanying language aid. If you would like a language aid, please indicate your choice below.

Arabic German Korean Turkish

Chinese (Simplified) Hebrew Portuguese (Brazilian)

Chinese (Traditional) Italian Russian

French Japanese Spanish

I have read and understand all the policies and procedures in the Certification Handbook. I have read and accept the terms and responsibilities outlined in the PMI Code of Ethics and Professional Conduct and in the PMI Certification Application/Renewal Agreement.

I declare that all the information I have provided on all pages of this application is true and accurate. I understand that misrepresentations or
incorrect information provided to PMI can result in disciplinary action(s), including suspension or revocation of my eligibility or certification.

I understand that I must complete any coursework prior to sitting for the exam. I understand that I may be selected for audit at any time.
Signature Date

Certification application continues on the next page. Payment of the certification fee is expected to be received with the paper application. To expedite processing, apply online at https://certification.pmi.org

YOUR INFORMATION | EXPERIENCE VERIFICATION | EDUCATION | GENERAL INFORMATION | PAYMENT

CAPM Certification Application

PAGE 6 OF 6 | PAYMENT

Applicants are encouraged to apply using the online certification system, but may elect to pay the fees under separate cover. Use this payment form to submit your fees by postal mail or submit payment through the online certification system.

PAYMENT OPTIONS

Check MasterCard Visa Bank Transfer American Express Diners Club Discover
Credit Card #: Exp. Date:

Signature

EXAMINATION FEES Fees subject to change without notice.

After determining your membership status and your examination administration preference please place an X next to the appropriate option below and note the associated fee in the box marked TOTAL. If you are applying to take a paper-based examination please indicate your preferred test site, group testing number and date. This information can be located at www.prometric.com/pmi. Examination Administration Type U.S. Dollars US$225 US$300 U.S. Dollars US$225 US$300 Euros 185 250 Euros 185 250 Site Group Testing No. Date (MM/DD/YY)

Computer-Based Testing member* Computer-Based Testing nonmember Examination Administration Type Paper-Based Testing member* Paper-Based Testing nonmember

**Calculate and add Canadian resident tax (if applicable) TOTAL

*The member rate will only apply to candidates who are members of PMI in good standing at the time your application is approved. If PMI membership is obtained after this application has been submitted, PMI will not issue a refund. Candidates interested in becoming members of PMI at the time of application for the credential can submit their PMI membership application and credential application at the same time and receive the member rate. To download a copy of the PMI membership application, please visit the membership area of the PMI website. **CANADIAN TAX INFORMATION Canadian billing addresses: In accordance with Canadian tax law, taxes are collected on all certification-related products. The rate of tax varies depending on the province billing address you use. Tax calculations by province are 15% for Nova Scotia, 13% for New Brunswick, Newfoundland/ Labrador and Ontario; 14.975% for Quebec, 12% for British Columbia and 5% for all remaining provinces. Online applications will automatically calculate tax. Downloaded applications will require insertion of applicable tax. If your employer is paying for your membership and has been granted tax-exempt status by the appropriate Canadian authorities, you will not be able to submit your application on-line. You will need to mail or fax your membership application along with a tax-exempt certification meeting the specifications of the Canadian government. GST/HST registration: 897944807RT0001; QST registration: 1202723001TQ0001

YOUR INFORMATION | EXPERIENCE VERIFICATION | EDUCATION | GENERAL INFORMATION | PAYMENT