Nutrient Management EXAM Registration Form

For more information regarding Nutrient Management Exams and to register by phone call: 1-855-648-1444 Please fill in the information below ( * indicates required information )
* Name (First, Middle, Last) full name as it appears on your government issued identification (i.e. drivers licence) * Home Mailing Address (include 911, RR # and/or P.O. Box #) * City/Town: * E-mail Address Work Address Company Name: Work Address ( Number, Street, Apt/Unit) City/Town Work Email Postal Code Work Telephone Work Fax * Postal Code: Date of Birth (mm/dd/yyyy) * Home Telephone Home Fax

Print clearly in ink

Examination Request Fill in the appropriate information below

(Please see the NM EXAM Schedule posted online at: http://www.nutrientmanagement.ca/ )

NOTE: If you are registering for the Broker/PMAB/Technician Licence exam to be written at the end of the scheduled course please fill in the date and location of the scheduled course in the Exam Date and Exam Location boxes below
Exam Have you taken these required courses? (check for yes) Introduction to Nutrient Management Agricultural Operation Strategy or Plan Development Certificate (AOSPDC) Regulations & Protocols How to Prepare a Nutrient Management Strategy and Plan (Using NMAN) Broker Certificate Course Exam Date Requested Exam Location Requested

Broker Certificate Prescribed Materials Application Business Licence (PMAB) Combined Exam Land Application Exam Only

Prescribed Materials Application Business Licence Course

Introduction to Nutrient Management Non-Agriculture Source Material (NASM)( Plan Development Certificate NASM Plan Developers Course How to Prepare a NASM Plan Using NMAN3 Nutrient Application Technician Licence Course

Nutrient Application Technician Licence

Page 1 of 3

Nutrient Management EXAM Registration Form

For more information regarding Nutrient Management Exams and to register by phone call: 1-855-648-1444 Payment (Forms received without payment will not be processed.) Examination fee: $150.00
Payment by: (Select one) Cheque Visa Mastercard Do not send cash. (No refunds given)

Make cheque payable to University of Guelph.

Total Payment =
Credit Card # Card Holders Name Card Holders Signature Verification and Consent By signing this application, I hereby consent to having my personal information contained on this form shared with the University of Guelph, Ridgetown Campus, and The Ontario Ministry of Agriculture, Food and Rural Affairs for the purposes of completing the Nutrient Management Examination. Expiry Date CVV code #

Applicant Signature:

Date:

Please complete this form, including signature and date, and return with your payment to: By Mail: Mitton House University of Guelph, Ridgetown Campus Attn: Mary Marg McDonald 120 Main St. East Ridgetown ON N0P 2C0 519-674-1512 (if paying with Visa or MasterCard)

By Fax:

Receiving Your Exam Confirmation You will receive an Exam Confirmation after your registration is processed, and will only be registered for the requested exam(s) if you meet the requirements for taking the exam. If you do not receive your Exam Confirmation in a timely manner, please call us at 1-855-648-1444 You will receive a receipt after your payment has been processed. *Note: All correspondence will be directed to your Home Address/E-mail Address

Page 2 of 3

Nutrient Management EXAM Registration Form

For more information regarding Nutrient Management Exams and to register by phone call: 1-855-648-1444
Notice of Collection and Use of Personal Information Personal information is collected under the authority of section 42(2) of the Nutrient Management Act, 2002, S.O. 2002, c. 4, as amended [NMA]. The information that is collected will be used by the Ministry of Agriculture, Food and Rural Affairs and/or their agents for administrative purposes, including: (a) the support of the certification and licensing program under the NMA, including future communications, research, training, certification, program development, plan approvals, monitoring and compliance; and (b) will be added to an informational database. The information collected may be subject to disclosure under the Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F. 31, as amended. By registering for the aboveidentified course or exam and completing and signing this form, the applicant consents to these terms and conditions. If you have any questions or require further information, please contact the Program Manager, Business Development and Training, Ridgetown Campus at 519-674-1500, x.63576

Page 3 of 3