Test Administrator Payment Request Form – Registry of Interpreters for the Deaf

This form is for test administrator to request payment for exams administered.

Name of TA*
First Last
TA RID ID*
Phone
Email*
Test Site Name*
Site Number*
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List*
Candidate Name Member # Exam Date Exam Name Exam Form (if applicable) Amount
Total Examinations*

Performance Examinations - $25 per each candidate tested*
Written Examinations - $35 per examination administration date*
TOTAL to be paid by check*
Name
Make Check Payable to:
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Test Site Fees
Performance Examination Processing Fee - $5 each candidate tested
is this check payment address the same as above?*
- Yes
- No
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Candidate Name	Member #	Exam Date	Exam Name	Exam Form (if applicable)	Amount

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