Recertification CMD Application

Certified Master Dealer®
Recertification Application***
(Continuing Education)

There is a $995 course fee for a current CMD
to complete this course for recertification and continuing education.


* Please indicate the date that you would like to attend:
November 20-23 , 2008

First Name,
MI, Last Name:

__________________________________________________________________________

Title / Position:

__________________________________________________________________________

Company Name:

__________________________________________________________________________

Mailing Address:

__________________________________________________________________________

City, State, Zip:

__________________________________________________________________________

Phone, Fax:

__________________________________________________________________________

Email, Website:

__________________________________________________________________________

Dealer License #:

__________________________________________________________________________

NIADA Membership #:

__________________________________________________________________________

CMD Certification /
Recertification Date:

__________________________________________________________________________



There is a $995 fee that must accompany this form.
PAYMENT INFORMATION: Enclosed is a check in the amount of $_____________________________
Visa MasterCard _____________________________________ Cardholder's Name ________________________________________________ Card Number	Amercan Express Discover __________________________________________ Expiration Date __________________________________________ Cardholder's Signature

For Office Use Only
Date Received	Approved

Please complete this application and submit with the fee to:

Georgia Brown, Director of Education
NIADA
2521 Brown Blvd.
Arlington, TX 76006
Fax: 817-649-5866