NCi
EPA Technician Certification
 Order Form 
Please complete this form, submit on-line, or fill it out, print it and fax or mail it with payment to us.
Fax, to 361/668-0036 or 361/664-3215
Thank you!

Customer Information

Your entry must match the name and address on your credit card, or your bank may decline the offer. All information is kept confidential unless you tell us otherwise. Your telephone or fax number helps us contact you for technical and billing questions.

Please feel free to write other information you think is necessary

FIRST NAME
MIDDLE
   LAST

STREET ADDRESS

CITY
STATE
ZIP CODE

Home phone (with area code)
Work phone (with area code))

Company name 
Your social security Number

Date of birth
Picture ID num. (Drivers license, etc.)
Enter type of license desired
Type I 
Type II
Type III
Universal		 Enter language
Preferred
English
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Other (explain)
Special fees apply


Book & exam $150


Additional amounts if any


Optional Express Service $15 (same day process priority mail back to you)


Total
Any additional comments & special instructions if any

Your Email Address

E-MAIL ADDRESS (one address only, no Web sites) i.e.,yourname@xyz.com(optional)

Payment Information

All of your payment information is kept strictly confidential.

NCi

 		   If paying by credit card, enter information below.
CARD TYPE:
(Circle One)		 American Express | Visa | Master Card | Discover
CARD NUMBER: CARD EXPIRES:

YOUR SIGNATURE:
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Money Order: Make money orders PAYABLE TO NCi drawn from a U.S. bank or from an international bank with funds specified explicitly as U.S. dollars. Please send this completed form with your order.
Member of
TimcoUSA
Payable to NCi
Print & Mail or Fax
361/668-0036 or 361/664-3215
427 So. Reynolds St.    Alice, Texas 78332
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