National Level Intent to Certify Form

National Level Intent to Certify

This form is due by December 1 for the upcoming calendar year.
Candidate Name*
Club/Center Name*
Club/Center Name
Current HM Certification*
HM Certification
Current Flat Certification*
Over Fences Certification
Current Over Fences Certification*
Over Fences Certification
Address*
City/State/Zip*
Mobile Phone*
E Mail*
example@example.com
Emergency Contact Name*
Relationship*
Mobile Phone*
E Mail*
example@example.com

Mount Information
Age*
Breed*
Sex*
Level of Training*
Strengths & Weaknesses*
Current Competition Level*
If this horse was not available for the testing would you have a replacement?*

YesNo

Declarations

I understand that my deposit is non-refundable and will be applied to the facility fee.
Candidate Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature (if a minor; if not a minor sign your name again)*

Clear
Date*

MonthDayYear
Date

Payment
prevnext( X )
National Level Testing Deposit
$50.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty: