ETA Certification Maintenance Form

ETA Certification Maintenance Form
STEP 1: Your Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Phone Number (Outside US)*

Country CodeArea CodePhone Number
Email*
example@example.com
Social Security # (Last 4 digits only)
Date of Birth*

MonthDayYear
Birth Date

MonthDayYear
Date
Years of electronics experience/education:
In the field*
Trade School*
College*
STEP 2: Continuing Education/Contact Hours

Please allow four weeks for receiving and processing of documentation materials.
Any Continuing Education documentation noted below must be attached in STEP 5

Maintenance certifications submit 10 hours of continuing education (40 total over 4 year period) OR Employer Verification Form. $25 maintenance fee per year ($100 total over 4 year period).

Maintenance with Hands-On certifications submit 6 hours of continuing education (24 total over 4 year period) AND Employer Verification Form. $25 maintenance fee per year ($100 total over 4 year period).

These contact hours may be in the form of:
- Technical webinars (must relate to certification being maintained and have completion certificate)
- Graduation certificates (must relate to certification being maintained)
- College credit transcripts (must relate to certification being maintained)
- Technical training sessions or courses from vendors (completion certificate required)
- Association or manufacturer/supplier-sponsored conferences or seminars (receipt required)
- Military training classes
- Actively serving on ETA committees as a Subject Matter Expert
- Publication of technical article or research
- Submission of an article for ETA's High Tech News magazine. Email the editor for more information at editor@etai.org
- eITprep (Fiber Optics, Electronics, Customer Service, and Smart Home), Professor Fix-It (Electronics), Bluerock Station (Solar PV), and other online self-study courses
* Some types of classes may not contain sufficient material to qualify for full credit toward continuing education. In those cases, ETA will give individuals a lesser credit for these classes, subject to evaluation.

** Continuing education must be related to an individual's certification(s) being maintained.
Continuing Education Course/Training
STEP 3: Employer Information
Present Employer*
Years Employed*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone Number*
Employer Phone Number (Outside US)*

Country CodeArea CodePhone Number
Supervisor*

First NameLast Name
STEP 4: Payment

My Products

Certification Maintenance - one (1) year

$25.00

Maintenance catch-up - two (2) years

$50.00

Maintenance catch-up - three (3) years

$75.00

Maintenance catch-up - four (4) years

$100.00

Certification Maintenance - one (1) year w/ Late Fee

$100.00

Maintenance catch-up - two (2) years w/ Late Fee

$125.00

Maintenance catch-up - three (3) years w/ Late Fee

$150.00

Maintenance catch-up - four (4) years w/ Late Fee

$175.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Email for receipt
example@example.com
STEP 5: Upload Documentation
Upload Documents

Cancelof
STEP 6: Signature
Signature*
Please PRINT your form before submitting!

* If your form does not submit, please scroll back up and see if there are errors that need addressed.
Should be Empty:

ETA Certification Maintenance Form

STEP 1: Your Information

STEP 2: Continuing Education/Contact Hours

STEP 3: Employer Information

STEP 4: Payment

STEP 5: Upload Documentation

STEP 6: Signature