2012 APPLICATION FOR REGULATORY AFFAIRS CERTIFICATION (RAC) EXAMS SPRING APPLICATION DEADLINE: 15 FEBRUARY 2012 [LATE DEADLINE: 8 MARCH 2012] AUTUMN APPLICATION DEADLINE: 15 AUGUST 2012 [LATE DEADLINE: 8 SEPTEMBER 2012] SELECT EACH EXAM YOU ARE APPLYING TO TAKE UNITED STATES (US) SPRING TESTING CYCLE: 1 APRIL – 31 MAY 2012 CANADA (CAN) EUROPEAN UNION (EU) GENERAL SCOPE (GEN SCOPE) UNITED STATES (US) AUTUMN TESTING CYCLE: 1 OCTOBER – 30 NOVEMBER 2012 CANADA (CAN) EUROPEAN UNION (EU) GENERAL SCOPE (GS) CANDIDATE CONTACT INFORMATION FIRST NAME MI LAST NAME RAPS MEMBER # (if applicable) JOB TITLE DEPARTMENT ORGANIZATION BUSINESS ADDRESS CITY STATE/PROVINCE POSTAL CODE COUNTRY BUSINESS TELEPHONE EXT COUNTRY CODE HOME PHONE BUSINESS EMAIL OTHER EMAIL HOME ADDRESS CITY STATE/PROVINCE POSTAL CODE COUNTRY SELECT EMAIL AND MAIL ADDRESS FOR RAC CORRESPONDENCE EMAIL HOME BUSINESS MAIL HOME BUSINESS CANDIDATE PROFILE (COMPLETE EACH SECTION) POSITION/TITLE HIGHEST EARNED DEGREE CEO/president Associate Vice president Director Manager Project Manager Specialist Associate Coordinator Consultant Bachelors/Baccalaureate Masters Doctorate DDS, DMD DVM JD MD PhD PharmD ScD YEAR ENTERED REGULATORY PROFESSION: NAME FOR RAC CERTIFICATE How were you referred you to the RAC program (check one) Supervisor Colleague HR at organization University instructor/advisor RAPS publications/materials RAPS.org Please enter your name EXACTLY as you would like it to appear on a certificate If you plan to take the RAC examination in a location outside of North America, please indicate the country that is your first preference in selecting an examination site: APPLICATION AGREEMENT I acknowledge that I have read and understand the RAC policies and procedures contained in the Candidate Guide. The information submitted in this application is complete and accurate. I believe I meet all eligibility requirements for the RAC exam. I authorize RAPS to make any inquiries deemed necessary to verify my credentials. I understand that false information may be cause for denial of this application or loss of the RAC credential. I allow RAPS to use information from my application and from the examination for the purpose of aggregate statistical analysis, provided that any personal information or identifiers are removed. I understand and agree to the policies related to withdrawing from the examination, presented in the Candidate Guide. Furthermore, I acknowledge that I have read and understand all of the tenets outlined in the Code of Ethics for Regulatory Professionals. Signature Date PAYMENT SELECTION SPRING CYCLE: FIRST TIME APPLICANT AND REAPPLICATION (PER EXAM) RAPS MEMBER PRICING (US$) *NONMEMBER PRICING (US$) $325 $425 BY 15 February 2012 LATE DEADLINE (8 March 2012) $510 $610 BY 15 February 2012 LATE DEADLINE (8 March 2012) AUTUMN CYCLE: FIRST TIME APPLICANT AND REAPPLICATION (PER EXAM) RAPS MEMBER PRICING (US$) $325 $425 BY 15 August 2012 LATE DEADLINE (8 September 2012) *NONMEMBER PRICING (US$) $510 $610 BY 15 August 2012 LATE DEADLINE (8 September 2012) * FOR NONMEMEBRS: Application fee includes a one‐year RAPS membership. No additional payment is required. Membership fees are non‐refundable and non‐transferable. If you do not wish to become a member, please check here: PAYMENT METHOD AMEX MASTERCARD VISA CHECK # (payable in US dollars) PLEASE NOTE PER CANDIDATE GUIDE, CHECKS MUST BE CARD NUMBER RECEIVED BY DUE DATE OR APPLICATION MAY BE RETURNED EXPIRATION DATE BILLING ZIPCODE/POSTAL CODE NAME ON CARD SIGNATURE _ INTERNATIONAL WIRE TRANSFER: FAX A COMPLETED FORM AND COPY OF BANK WIRE CONFIRMATION TO CONFIRM YOUR REGISTRATION TO: RAPS ACCOUNT #702267562; ABA #061000104 SWIFT CODE SNTRUS3A; SUNTRUST BANK, RICHMOND, VA. MUST REFERENCE NAME OF REGISTRANT. ALL BANK CHARGES ARE THE RESPONSIBILITY OF THE PAYER. FOR ALL WIRE PAYMENTS: FAX (+1 301 770 2924) OR EMAIL (CERTIFICATION@RAPS.ORG) A COMPLETED FORM AND COPY OF BANK WIRE CONFIRMATION TO CONFIRM YOUR REGISTRATION.