Please provide the following information.
Ratings event:
(give name & location)
Date of event:
   
First Name:
Last Name:
Member Number:
Address:
 
City:
State/Province:
ZIP/Postal Code:
Country:
 
Home Phone:
Work Phone:
Mobile Phone:
Primary Email Address:
   
Club/Rink Affiliation:
Location/Date of most recent PSA educational event attended (or scheduled to attend):
   
Please indicate which exam(s) you wish to apply for:
First:
Second:
Alternate
(if one of the above is unavailable)
   
Late Fees:
(1/2 of the exam fee)
Check here if you are submitting this application after the deadline.
Application Fee: $5
Total Amount Due:
Card type:
Visa
MasterCard
Discover
Name on Card:
Card number:
Expiration date: /
   
PSA Cancellation Policy
30 days or more: 50% refund; less than 30 days: NO REFUND. Please review all information carefully.