PMI-SP Certication Application

PAGE 1 OF 6 | YOUR INFORMATION

Tips for completing this form: Hand-write your information clearly in blue or black ink onto a printed form and submit it by postal mail. Type your information into the PDF. If you have PDF-editing software like Adobe Acrobat or Foxit Reader, you can save your data. Otherwise, you will only be able to type your information, then print out the form and send it to PMI. All information and documentation must be in English. Faxed or scanned copies will not be accepted. PMI Member ID#: If you are a PMI member, you have an ID number. To nd your ID number, log in to myPMI and select Prole from the top navigation, then select Membership Prole from the left navigation. If you have any questions, you may contact PMI Customer Care at +1 610-356-4600, or send an email to [email protected].

Instructions: In this section you are being asked to PRINT your name for three separate purposes. It is very important that you complete this section carefully. Section 1. Please print your name as you wish to be referred to in correspondence from PMI. Section 2. Please print your name as it appears on your government-issued identication that you will present at the testing center. Section 3. Please print your name as you wish it to appear on your PMI-SP certicate. Section 1. Name for correspondence from PMI: Prex (Mr., Mrs., Ms., Dr.): First Name (given name): Middle Name: Sufx:

Last Name (family name, surname). Candidates with only a single name should use last name eld:

Section 2. Name on government-issued identication: Check here if same as above. Prex (Mr., Mrs., Ms., Dr.): First Name (given name): Middle Name: Sufx:

Last Name (family name, surname). Candidates with only a single name should use last name eld:

Section 3. Name for your PMI-SP certicate: Check here if same as above. Prex (Mr., Mrs., Ms., Dr.): First Name (given name): Middle Name: Sufx:

Last Name (family name, surname). Candidates with only a single name should use last name eld:

CONTACT INFORMATION
Prefered Mailing Address: Home Address:

Home

Business
City: Country:

Billing Address*:

Home

Business

*If paying by credit card, your billing address must match the address on your credit card statement.

State/Province/Territory: Zip/Postal Code:

Business Address:

Business Name: City: Country: State/Province/Territory: Zip/Postal Code:

PRA-200-2013

PMI-SP Certication Application

PAGE 2 OF 6 | YOUR INFORMATION (Continued)
Preferred E-mail: E-mail:

Personal Work

Preferred Phone: Phone:

Home Business Mobile

Extension:

Preferred Fax: Fax:

Home Business

Applicants Primary Industry:

Aerospace Automotive Business Communications

Construction Consulting Education Engineering

Finance Healthcare Human Resources Information Technology

Manufacturing Pharmaceuticals Telecommunications Other: ___________________________

Highest level of education attained at the time of this application:

High School Diploma / Global Equivalent Associates Degree / Global Equivalent

Year diploma/degree was awarded: Address:

Bachelors Degree / Global Equivalent Masters Degree / Global Equivalent

Name of High School, College or University: City: Country:

Doctoral / Global Equivalent

State/Province/Territory: Zip/Postal Code:

Field of Study:

Communications Computer Science Education

Engineering Finance Liberal Arts

Marketing Mathematics Pharmaceuticals

Science Other ___________________________

PMI-SP Certication Application

PAGE 3 OF 6 | EXPERIENCE VERIFICATION
Use the Experience Verication form to document at least 3,500 hours work experience in project scheduling if you hold a Bachelors degree/global equivalent (within the past 5 years), or 5,000 hours work experience in project scheduling if you hold a high school degree (within past 5 years). Number your projects and submit one set of Experience Verication Forms per project. Please copy these forms if you require additional space. Project #: Project Title: Project Role: Start Date (MM/YYYY): Project Industry: Completion Date (MM/YYYY):

Project Contributor
Job Title: Organization Address: City: Country: Phone (Country Code, Area/State/City Code, Phone Number):

--select one-Organization Name: State/Province/Territory: Zip/Postal Code: Extension:

Please identify and provide current information for your primary contact on this project so that PMI can verify your professional work experience. First Name (given name): Last Name (family name, surname):

Contact Relationship:

Project Sponsor Manager/Director Client Primary Stakeholder

Extension: E-mail:

Phone (Country Code, Area/State/City Code, Phone Number):

For each project, please list the number of hours you have spent leading and directing the tasks noted in the ve process groups. Next, add the total hours per process and record that number in the boxes at the bottom of each section. Remember to record the project number that corresponds with the project documented at the top of the Experience Verication form. Please ensure your description is between 50-80 words (300-500 characters). Schedule Strategy:

Schedule Planning and Development:

Schedule Monitoring and Controlling:

Schedule Closeout:

Stakeholder Communication Management:

Total Hours for Project:

PMI-SP Certication Application

PAGE 4 OF 6 | EDUCATION
Candidates holding a bachelors degree or global equivalent, document a minimum of 30 contact hours of education within the specialty area of project scheduling. Candidates holding a high school diploma, associates degree or global equivalent, document a minimum of 40 contact hours of education within the specialty area of project scheduling. One contact hour is equivalent to one actual hour of training or instruction received. There is no timeframe associated with this requirement; therefore, candidates can document all education within the specialty area of project scheduling regardless of when it was accrued. However, the course work must be complete at the time the application is submitted.

A. B. C. D. E. F.

PMI Registered Education Providers (R.E.P.s)* Courses or programs offered by PMI chapters or communities of practice* Employer/company-sponsored programs Training companies or consultants Distance-learning companies,including an end of course assessment University/college academic and continuing education programs

The following education does not satisfy the education requirements:

PMI chapter meetings Self-study (e.g., reading books)

*Courses offered by PMI R.E.P.s, PMI chapters and communities of practice, or PMI, are pre-approved for contact hours in fulllment of eligibility requirements.

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

Course Title: Start Date (MM/DD/YYYY):

Institute Name: Completion Date (MM/DD/YYYY): Hours: Qualifying Hours:

Category (A-F):

PMI-SP Certication Application

PAGE 5 OF 6 | GENERAL INFORMATION
Please include me in:

Communications from PMI regarding its products, events and services

Third Party Mailing Lists Mailings Mailings from organizations other than PMI

OPTIONAL INFORMATION
The following questions are optional, and you may choose not to answer them. Reason you are applying for this certication:

Employer Required

Employer Suggested

Personal Development

SPECIAL ACCOMODATIONS FOR EXAMINATION

Check here if you have special needs which may impair your ability to take the examination. Please complete the Special Accommodations Form. The completed form and supporting medical documentation must be returned to PMI along with your completed credential application.

I have read and understand all the policies and procedures in the Certication Handbook. I have read and accept the terms and responsibilities outlined in the PMI Code of Ethics and Professional Conduct and in the PMI Certication Application/Renewal Agreement. I declare that all the information I have provided on all pages of this application is true and accurate. I understand that misrepresentations or incorrect information provided to PMI can result in disciplinary action(s), including suspension or revocation of my eligibility or certication. I understand that I must complete any coursework prior to sitting for the exam. I understand that I may be selected for audit at any time.

Signature

Date

Certication application continues on the next page. Payment of the certication fee is expected to be received with the paper application. To expedite processing, apply online at https://certication.pmi.org

PMI-SP Certication Application

PAGE 6 OF 6 | PAYMENT
Applicants are encouraged to apply using the online certication system, but may elect to pay the fees under separate cover. Use this payment form to submit your fees by postal mail or submit payment through the online certication system. PMI Member ID#: If you are a PMI member, you have an ID number. To nd your ID number, log in to myPMI and select Prole from the top navigation, then select Membership Prole from the left navigation. If you have any questions, you may contact PMI Customer Care at +1 610-356-4600, or send an email to [email protected]. First Name (given name): Middle Name: Sufx:

Prex (Mr., Mrs., Ms., Dr.):

Last Name (family name, surname). Candidates with only a single name should use last name eld:

PAYMENT OPTIONS

Check MasterCard Visa Bank Transfer American Express Diners Club Discover
Credit Card #: Exp. Date:

Signature

EXAMINATION FEES Fees subject to change without notice.

After determining your membership status and your examination administration method, please check the box next to the appropriate option below and note the associated fee in the box marked TOTAL. If you are applying to take a paper-based examination please indicate your preferred test site, group testing number and date. This information can be located at www.prometric.com/pmi. If you are unsure whether you should be applying for a Computer-Based Test or a Paper-Based Test, please refer to your credential handbook for additional information. Examination Administration Type U.S. Dollars US$520 US$670 U.S. Dollars US$415 US$565 Euros 430 555 Euros 345 475 Site Group Testing No. Date (MM/DD/YY)

Computer-Based Testing member* Computer-Based Testing nonmember Examination Administration Type Paper-Based Testing member* Paper-Based Testing nonmember

**Calculate and add Canadian resident tax (if applicable) TOTAL

*The member rate will only apply to candidates who are members of PMI in good standing at the time your application is approved. If PMI membership is obtained after this application has been submitted, PMI will not issue a refund. Candidates interested in becoming members of PMI at the time of application for the credential can submit their PMI membership application and credential application at the same time and receive the member rate. To download a copy of the PMI membership application, please visit the membership area of the PMI website. **CANADIAN TAX INFORMATION Canadian billing addresses: In accordance with Canadian tax law, taxes are collected on all certication-related products. The rate of tax varies depending on the province billing address you use. Tax calculations by province are 15% for Nova Scotia, 13% for New Brunswick, Newfoundland/Labrador and Ontario; 14.975% for Quebec, 12% for British Columbia and 5% for all remaining provinces. Online applications will automatically calculate tax. Downloaded applications will require insertion of applicable tax. If your employer is paying for your membership and has been granted tax-exempt status by the appropriate Canadian authorities, you will not be able to submit your application online. You will need to mail or fax your membership application along with a tax-exempt certication meeting the specications of the Canadian government. GST/HST registration: 897944807RT0001; QST registration: 1202723001TQ0001

Certication Examination

Special Accommodations Form

The PMI Certication Department complies with the Americans with Disabilities Act of 1990. To ensure equal opportunities for all qualied persons, the Certication Department will make reasonable accommodations for candidates when appropriate. If you require special accommodations related to a disability in order to take the examination, you must complete this form and submit it with your examination application (you can request special accommodations through the online certication system when you apply online). PMI Member ID#: If you are a PMI member, you have an ID number. To nd your ID number, log in to myPMI and select Prole from the top navigation, then select Membership Prole from the left navigation. If you have any questions, you may contact PMI Customer Care at +1 610-356-4600, or send an email to [email protected].

First Name (given name): Last Name (family name, surname). Candidates with only a single name should use last name eld: E-mail:

Middle Name:

Which certication examination are you planning to take at this time?

CAPM PMP

PgMP

PMI-RMP

PMI-SP

PMI-ACP PfMP

Please identify the disability that substantially limits one or more of your sensory, manual, or speaking skills (e.g., disability that signicantly impairs your ability to arrive at, read, or otherwise complete, the examination):

Please list the special testing accommodation requested. Use a separate sheet if more space is needed:

NOTE: You must provide PMIs Certication Department with written documentation from an appropriate health care professional supporting the need for the accommodation that you are requesting.This documentation must include a diagnosis of your health condition and a specic recommendation for the type of special testing accommodations you will require. This completed form and supporting medical documentation must be submitted to PMI along with your completed certication application. Failure to include supporting medical documentation will cause a delay in processing your application. PMI will not pay any costs you may incur in obtaining this information.

Signature

Date

PRA-234-2011(06-13)

PMI prefers that you apply using the online certication system at PMI.org 14 Campus Blvd | Newtown Square, PA 19073-3299 USA | Fax: +1 610 239 2257

Certication Reexamination Form

Page 1 of 3
In order to schedule to retake a PMI examination, complete and submit this form by mail or fax to PMI Global Operations Center, Attn. Certication Department. The reexamination rate is only valid within your one-year eligibility period. Before applying for reexamination, please review PMIs reexamination policy located in the handbook. Please complete this form in its entirety in one of the following ways: 1. Print out the form and hand-write your information clearly in blue or black ink using ALL CAPITAL LETTERS. 2. Save the PDF to your desktop and open in Adobe Acrobat. Type in all your information, save the document, print it out and submit it. PMI Member ID#: If you are a PMI member, you have an ID number. To nd your ID number, log in to myPMI and select Prole from the top navigation, then select Membership Prole from the left navigation. If you have any questions, you may contact PMI Customer Care at +1 610-356-4600, or send an email to [email protected].

CONTACT INFORMATION
Please print your name as it appears on your government issued identication, that you will present at the testing center. First Name (given name): Last Name (family name, surname). Candidates with only a single name should use last name eld: Address: City: Country: Preferred Email: Phone Number: State/Province/Territory: Zip/Postal Code: Extension: Middle Name:

PAYMENT INFORMATION

Check Master Card Visa Bank Transfer American Express Diners Club Discover
Credit Card #: Exp. Date:

Signature

Date

REEXAMINATION FEES (Payable in U.S. Dollars and Euros only)

After determining your PMI membership status and your examination administration type, please place an X next to the appropriate option and note the associated fee in the box marked TOTAL for the PMI examination you plan to retake (CAPM, PMP, PgMP, PMI-RMP, PMI-SP, PMI-ACP, or PfMP). PMI uses computer-based testing (CBT) as the standard method of administration for its examinations. Candidates who live within 186.5 miles/300km of a Prometric CBT site, must take a CBT examination. If you are applying to take a paper-based examination please indicate your preferred test site, group testing number and date. You can nd this information online at www.prometric.com/pmi.

CAPM Reexamination Administration Fees

Computer-Based Testing member* Computer-Based Testing nonmember Paper-Based Testing member* Paper-Based Testing nonmember

US Dollars $150 $200 $150 $200

Euros 200 170 125 170 Site Group Testing No. Date (mm/dd/yy)

** Calculate and add Canadian resident tax (if applicable)

TOTAL

PMI prefers that you apply using the online certication system at PMI.org

PRA-233-2012(06-13)

Certication Reexamination Form

Page 2 of 3

PMP Reexamination Administration Fees

Computer-Based Testing member* Computer-Based Testing nonmember Paper-Based Testing member* Paper-Based Testing nonmember

US Dollars $275 $375 $150 $300

Euros 230 315 125 250 Site Group Testing No. Date (mm/dd/yy)

** Calculate and add Canadian resident tax (if applicable)

TOTAL

PgMP Reexamination Administration Fees

Computer-Based Testing member* Computer-Based Testing nonmember Paper-Based Testing member* Paper-Based Testing nonmember

US Dollars $600 $800 $500 $700

Euros 490 655 410 570 Site Group Testing No. Date (mm/dd/yy)

** Calculate and add Canadian resident tax (if applicable)

TOTAL

PMI-SP Reexamination Administration Fees

Computer-Based Testing member* Computer-Based Testing nonmember Paper-Based Testing member* Paper-Based Testing nonmember

US Dollars $335 $435 $270 $370

Euros 280 365 225 310 Site Group Testing No. Date (mm/dd/yy)

** Calculate and add Canadian resident tax (if applicable)

TOTAL

PMI-RMP Reexamination Administration Fees

Computer-Based Testing member* Computer-Based Testing nonmember Paper-Based Testing member* Paper-Based Testing nonmember

US Dollars $335 $435 $270 $370

Euros 280 365 225 310 Site Group Testing No. Date (mm/dd/yy)

** Calculate and add Canadian resident tax (if applicable)

TOTAL

PMI-ACP Reexamination Administration Fees

Computer-Based Testing member* Computer-Based Testing nonmember Paper-Based Testing member* Paper-Based Testing nonmember

US Dollars $335 $395 $285 $345

Euros 280 330 240 290 Site Group Testing No. Date (mm/dd/yy)

** Calculate and add Canadian resident tax (if applicable)

TOTAL

PMI prefers that you apply using the online certication system at PMI.org

Certication Reexamination Form

Page 3 of 3

PfMP Reexamination Administration Fees

Computer-Based Testing member* Computer-Based Testing nonmember Paper-Based Testing member* Paper-Based Testing nonmember

US Dollars $600 $800 $500 $700

Euros 490 655 410 570 Site Group Testing No. Date (mm/dd/yy)

** Calculate and add Canadian resident tax (if applicable)

TOTAL

* The member rate will only apply to candidates who are members of PMI in good standing at the time your application is approved. If PMI membership is obtained after this application has been submitted, PMI will not refund the difference. Candidates interested in becoming members of PMI at the time of application can submit their PMI membership application and the application at the same time and receive the member rate. To download a copy of the PMI membership application, please visit the membership area of the PMI website. **CANADIAN TAX INFORMATION Canadian billing addresses: In accordance with Canadian tax law, PMI collects taxes on member dues, application fees, and other payments. Canadian residents should include applicable taxes in the space provided. The rate of tax varies depending on the province billing address you use. Tax calculations by province are 15% for Nova Scotia, 13% for New Brunswick, Newfoundland/ Labrador and Ontario; 14.975% for Quebec and 5% for all remaining provinces. Online applications will automatically calculate tax. Downloaded applications will require insertion of applicable tax. Please note that if your employer is paying for this purchase and has been granted tax-exempt status by the appropriate Canadian authorities, you will not be able to use online processing. You will need to mail your application and mail or fax a tax-exempt document meeting the specications of the Canadian government to the PMI Global Operations Center (fax: +1 610-771-4085). GST/HST registration: 897944807RT0001; QST registration: 1202723001TQ000

SPECIAL ACCOMMODATIONS FOR EXAMINATION

Candidates may request modication to the examination administration procedure due to disability, handicap, or other condition which may impair the ability of the candidate to take the exam. To request special testing accommodation, candidates must indicate their need on this form by checking the appropriate box below.

I am requesting the same special accommodation(s) that was approved for my previous examination. I am requesting special accommodation(s) for the rst time.

(Please complete the Special Accommodations form separately and submit it to PMI with your reexamination form)

LANGUAGE AID FOR EXAMINATION

All PMI examinations are administered in English, but assistance for the CAPM and PMP can be provided with an accompanying language aid. If you would like a language aid for the CAPM or PMP examination, please indicate your choice below.

Arabic Chinese (Simplied) Chinese (Traditional) French German Hebrew Italian

Japanese Korean Portuguese (Brazilian) Russian Spanish Turkish

PMI prefers that you apply using the online certication system at PMI.org