NAPIA - Certification Form

National Association of Public Insurance Adjusters

Learn About NAPIA > Certification Form

CPPA / SPPA Matriculation & Registration Application

Instructions: Complete Sections I through III. Submit with your educational credentials and enclose payment for the non-refundable $550 ($895 for non-members) matriculation and examination fee.

BOARD OF EXAMINERS

National Association of Public Insurance Adjusters
21165 Whitfield Place, #105
Potomac Falls, VA 20165
Telephone: (703) 433-9217
Facsimile: (703) 433-0369

SECTION 1: PERSONAL INFORMATION

Are you a NAPIA member?  Yes  No

        Full Name:  *
         Employer: 
 Business Address: 
             City: 
            State: 
              Zip: 
   Business Phone: 
       Fax Number: 
           E-mail:  *
		      
Residence Address:   
             City: 
            State: 
              Zip: 
  Residence Phone: 

       Date of Birth: 

PA License Number(s): 

Exam Selection:  CPPA Exam:    SPPA Exam: 

Test Period Selection  (Allow 3–4 months to thoroughly review the study material)

Make this selection carefully. Missed exam appointments will result in additional charges.

January 15 – March 15
April 15 – June 15
July 15 – September 15
October 15 – December 15

SECTION II: Provide Educational Background

College or University:
 Time Attended: 
Name of School: 
    City/State: 
Year Graduated: 


College or University:

 Time Attended: 
Name of School: 
    City/State: 
Year Graduated: 

College or University:

 Time Attended: 
Name of School: 
    City/State: 
Year Graduated: 

Education Notes / Comments:  




SECTION III: Provide Business or Professional Experience

Most Recent Employment:
Time Employed: 
     Position: 
Employer Name: 
   City/State: 

Previous Employment:
Time Employed: 
     Position: 
Employer Name: 
   City/State: 

Previous Employment:
Time Employed: 
     Position: 
Employer Name: 
   City/State: 
   
Employment Notes / Comments:



SECTION IV: Payment Information

Method of Payment:  Check  Credit Card
  Credit Card Co.: 
     Name on Card: 
    Credit Card #: 
  Expiration Date: 
     Today's Date: 7/3/2008

If paying by check, make payable to NAPIA

Upon acceptance into the CPPA or SPPA program, the candidate will be charged for the package of study material and examination fee as outlined on page 6 of the Registration packet. Study material will be shipped to the business address indicated on this form and the candidate's examination registration will be activated. See page 6 of the Registration packet for more information about study material and examination policies and procedures.