TAGME Registration - 2018 Assessment Retakes Question Title * 1. Demographic Information Name Institution/Program Specialty Program Address Address 2 City/Town State/Province ZIP/Postal Code Country Personal Email Address (NO .edu, .org or .gov allowed) Contact Phone Number OK Question Title * 2. Certificate Information Name as it should appear on your certificate Address to mail certificate Address 2 City/Town State/Province ZIP/Postal Code Country OK Question Title * 3. Will you need any special accommodations to take the assessment? Yes (Further information will be provided) No OK Question Title * 4. By checking the box below, I understand I am still bound by my positive affirmation of TAGME's Attestation Statement for Certification guidelines of my initial or maintenance of certification application. Agree Disagree OK Thank you for completing this registration. We will reach out in a few weeks with instructions to schedule your retake assessment date, location and time. OK DONE