2013 - 2014 Registration Form
Fields marked with an asterisk (*) are required.
Registration Fees
Active $75.00
Inactive $50.00
Retired $0.00
Late Fee $500.00
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*Type:
*Certificate Number:
*Last 4 Digits of SSN:
 
Note: To avoid paying a late penalty, online registration forms must be entered and credit card information processed on or before midnight central time on December 31, 2013. Registration renewals entered after this date are subject to a late renewal penalty. The penalty is $100 for renewals entered from January 1, 2014, through March 31, 2014. The penalty is $500 for renewals entered on or after April 1, 2014. After September 30, 2014, disciplinary hearings will be held.




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