This is an order form for the NECC Examination for NECT National Emergency Communications Telecommunicator - Level I.  Completion of this application form will result in a review of your qualifications by the NECC Board. If you qualify for the national exam, you will receive a confirmation in the mail from Professional Testing Corporation (PTC) with further instructions on finding a testing center. Complete all information requested on the Application.  Select one response only unless otherwise indicated.  Fields marked with an asterisk (*) are required. Starting at the top of the Application, enter your name, address, phone numbers, and a valid e-mail address.

CONTACT INFORMATION
First Name  *	MI	Last Name  *
HOME ADDRESS
Street Address  *			Apartment Number
City  *			State/Province  *
			-- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip/Postal Code  *
Home Phone  *
Fax
Valid E-mail Address  *

ELIGIBILITY AND BACKGROUND INFORMATION
Select only one response unless otherwise indicated.
A.	Eligibility route:  *
		6 months direct work experience in public safety communications
		Participation in a college level emergency communications course
		Completion of NECC Self-Study Course
			Yes
			No
B.	Which of the following best describes your job description:
		Call Taker
		Dispatcher
		Telecommunicator
		9-1-1 Operator
		Emergency Operator
		Police Clerk
		Fire Communicator
		Emergency Medical Dispatcher (EMD)
		Communications Trainer
		Training Manager
		Supervisor
		Manager
		Student
		Other

C.	Current Employer: (if applicable)
	Street Address	Suite/Room/Floor
	City	State/Province
		-- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
	Zip/Postal Code
	Work Phone
	Direct Supervisor

D.	Which best describes your current employer:
		Not currently employed
		9-1-1 PSAP
		Combined Center
		Police Department
		Fire Department
		Emergency Medical Services (EMS)
		Ambulance Service
		Alarm Company
		Military
		Private Organization
		Call Center
		Other
E.	What is your primary shift:
		Day
		Swing
		Grave
		Mid
		Other
F.	YEARS OF DIRECT EXPERIENCE IN PUBLIC SAFETY COMMUNICATIONS:  *
G.	Primary area your communications experience was gained:  *
		Not applicable
		Police
		Fire
		EMS
		Combined
		Other
H.	Highest academic level attained:  *
		Less than High School Graduate
		High School Diploma or equivalent
		Some College
		Associate's Degree
		Bachelor's Degree
		Master's Degree
		Doctoral Degree
		Other
I.	Other certifications held:  (Select all that apply.)  *
		None
		APCO
		EMD
		ENP
		NAED
		NCI
		Other
J.	Have you taken this examination before:  *
		No
		Yes

OPTIONAL INFORMATION
These questions are optional.  The information requested is to assist in complying with equal opportunity guidelines and will be used only in statistical summaries.  Such information will in no way affect your test results.
	Gender:		Age Range:		Ethicity:
	Male		Under 25		African American
	Female		25 to 29		Asian
			30 to 39		Hispanic
			40 to 49		Native American
			50 to 59		White
			60 and Over		Other

PAYMENT INFORMATION
NECC Certification Examination Registration:		US$
For NECC Pre-Cert OnLine College Course Registration and payment (required for those with no experience) go to www.cptc.edu

PAYMENT METHOD
Select which payment method you will be using, and follow the necessary instructions.
	Pay with Credit Card
	BILLING INFORMATION
	First Name:  *	MI	Last Name:  *

	Street Address:  * (as it appears on your statement)
	Apartment Number:
	City:  *	State:  *	Zip/Postal Code:  *
		-- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

	Credit card Number:	*
	Credit card Type:	MasterCard Visa American Express   *
	Expiration Date:  (Month/Year)	01 02 03 04 05 06 07 08 09 10 11 12 /		*  Last 2 digits for Year (Range: 2003~2020)
OR
	Pay with Agency Purchase Order
	Agency Name:	Purchase Order Number:     PO Authorizing Person Name:
OR
	Pay with personal or bank check
	Please mail your check to: NECC, PO Box 370, Sumner, WA 98390

AGREEMENT TO TERMS AND CONDITIONS  *
When you have completed all required information, read the statement and check on the agree box to agree to the terms and conditions.
I agree to the terms and conditions set forth in the Handbook for Candidates and I certify that the information in this application is accurate and correct.  I also certify that I am over the age of 18 and am authorized to use the credit card linked to this application, or the Agency PO has been approved, or the check will be mailed this date.
		Agree