National Level Intent to Certify
This form is due by December 1 for the upcoming calendar year.
Candidate Name
*
Club/Center Name
*
Please Select
Bath Pony Club
Brush Run Pony Club
Chagrin Valley Farms Pony Club Riding Center
Harts Run Hunt Pony Club
Hunters Run Pony Club
Lost Hounds Pony Club
Rolling Rock Hunt Pony Club
Club/Center Name
Current HM Certification
*
Please Select
C1 (must have passed C2-HM to be eligible to take HB test)
C2
HB
HA
HM Certification
Current Flat Certification
*
Please Select
D2
D3
C1
C2
C3
B
Over Fences Certification
Current Over Fences Certification
*
Please Select
D2
D3
C1
C2
C3
B
Over Fences Certification
Address
*
City/State/Zip
*
Mobile Phone
*
Format: (000) 000-0000.
E Mail
*
example@example.com
Emergency Contact Name
*
Relationship
*
Mobile Phone
*
Format: (000) 000-0000.
E Mail
*
example@example.com
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Test(s) Desired
Indicate which test(s) you are registering for:
*
H-B
H-A
C3-DR
C3-SJ
C3-EV
B-DR
B-SJ
B-EV
A-DR
A-SJ
A-EV
How are you preparing for this certification?
*
Is a mount required for your testing?
Yes
No
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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?
*
Yes
No
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Declarations
I understand that my deposit is non-refundable and will be applied to the facility fee.
Candidate Signature
*
Date
*
/
Month
/
Day
Year
Date
Parent/Guardian Signature (if a minor; if not a minor sign your name again)
*
Date
*
/
Month
/
Day
Year
Date
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Payment
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( X )
National Level Testing Deposit
$
50.00
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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