NEW LTA Invoice Form for CASLI

Invoice Request Form

Please fill out the form. Please submit a separate invoice for each calendar month (LTA invoices will be processed after the last of the month). If invoice is not received within 30 days from last day of previous month, then it will be considered as in-kind donation to CASLI.
Invoice Month*
Month in which exams were administered
Test Administrator Name*

First NameLast Name
Email*
yourname@example.com
Secondary Email (if needed)
yourname@example.com
LTA RID Member Number
Company/Agency Name *
Company/Agency Location *
City and State

Exam Name	Exam Type (Code)	Rate per exam
CASLI Performance Exam - NIC AND Case Studies Exam	NICS	$80
CASLI Performance Exam - CDI AND Case Studies Exam	CDICS	$80
CASLI Performance Exam - NIC ONLY	NICP	$50
CASLI Performance Exam - CDI ONLY	CDIP	$50
Case Studies Exam ONLY	CS	$50
CASLI Generalist Knowledge Exam - Fundamentals of Interpreting Multiple Choice Exam AND Case Studies Exam (by special request ONLY)	CGKE	$100
CASLI Generalist Knowledge Exam - Fundamentals of Interpreting Multiple Choice Exam ONLY	FOI	$65

Rows	Full Name	RID Member #	Exam Date	Exam Type (Code)	Amount
Candidate 1
Candidate 2
Candidate 3
Candidate 4
Candidate 5
Candidate 6
Candidate 7
Candidate 8

Total Amount for all exams administered on this invoice*
Payment by:*

Check PaymentDirect DepositThis is an In-Kind Donation
For Direct Deposit Payment:

If opt for direct deposit and you have not set up your direct deposit payment, please complete the Vendor Direct Deposit Enrollment Form. Should you have have any questions regarding the direct deposit form, please contact accounting@casli.org
Make payable to: (Name of individual or site payment is being sent to):*
Designated individual or site/company name payment is made out to.
Check mailed to:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this an in-kind donation?

YesNo
For payment by check, has there been any change to the payment mailing address?*

YesNoN/A (payment is received by Direct Deposit or in-kind donation)
Please make notes if there have been changes to address information or any information that needs to be shared with CASLI.
If there has been any changes with payment or address or anything, please contact accounting@casli.org to ensure payment is processed appropriately.

Invoice forms must be submitted monthly and within 30 (thirty) days of examination administration in order to be processed for payment. Please submit seperate invoices for each calendar month (LTA invoices will be processed after the last day of the month). If invoice is not received within 30 days from last day of previous month, then it will be considered as in-kind donation to CASLI.

I agree to abide by the stipulations outlined in the CASLI Official Agents and Agreement and Test Administrator's Online Manual. By submitting this invoice, I swear that all information here on this form is true, complete, and accurate.
LTA invoices are processed after the end of each calendar month. Any questions or concerns about LTA invoices may be emailed to Manager@casli.org
Signature*

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Invoice Request Form