Request Form for NARM CPM Certification Application Packet Portfolio Evaluation Process (PEP) Application Packet and Candidate Information Bulletin (CIB)

Please print while filling out the following in black ink.

Name: ______________________________________________________

Address:_____________________________________________________________________

City: ______________________________________ State/Province: _______________

Country: ________________________ Postal code: ___________________

Phone (home): ___________________ Phone (work): ___________________

Pager: ___________________ Fax: ___________________

Social Security Number: ________________________________ Date: __________________

Attached is my non-refundable:

__ Certified Check, or

__ Money Order made out to the North American Registry of Midwives (NARM) in U.S. funds (NARM does not accept personal checks), or

__ Please charge* this to my ___Visa or ___MasterCard.

          Card Number ____________________________  exp. date__________ 

          Signature________________________________

*There will be handling fee for all credit card requests and any application mailed outside the United States.

Personal or Business checks will be returned.

___  CPM Application Packet (for all routes of entry)        includes the Candidate Information Bulletin (CIB)	$50.00
___  Candidate Information Bulletin (without application packet)	$10.00

Mail this form and the accompanying fee to:

NARM Applications
PO Box 420
Summertown, TN 38483

NOTE: The application will be mailed to you by priority mail, and a signature will be required upon delivery.

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