HR Education Financial Assistance Program Application Form

The total fees are $1999.00, exam fee inclusive AND $1599.00, exclusive of exam fee.

This can be paid in 3, 6 or 12 equal installments.

Payment Plan Exam Fee Inclusive	1^st	2^nd	3^rd	4^th	5^th	6^th	7^th	8^th	9^th	10^th	11^th	12^th
3 Installment Plan	$667.00	$667.00	$667.00
6 Installment Plan	$334.00	$334.00	$334.00	$334.00	$334.00	$334.00
12 Installment Plan	$167.00	$167.00	$167.00	$167.00	$167.00	$167.00	$167.00	$167.00	$167.00	$167.00	$167.00	$167.00

Payment Plan Exam Fee Exclusive	1^st	2^nd	3^rd	4^th	5^th	6^th	7^th	8^th	9^th	10^th	11^th	12^th
3 Installment Plan	$533.00	$533.00	$533.00
6 Installment Plan	$267.00	$267.00	$267.00	$267.00	$267.00	$267.00
12 Installment Plan	$134.00	$134.00	$134.00	$134.00	$134.00	$134.00	$134.00	$134.00	$134.00	$134.00	$134.00	$134.00

Please Note: That candidates using this pre-payment (Monthly contribution) option will only participate in the SHRM Instructor Led

Classes AFTER payment have completed.

Candidates will also get their SHRM Learning systems booklets and online access ONLY after their payments have been completed.

However, candidates can opt out and request a refund, which is subject to a 25% surcharge.

50%

Name of Applicant*
First Last
Sex*
- Male
- Female
Marital Status*
- Single
- Married
- Divorced
- Widowed
- Other
Date of Birth*
Employment*
- Paid
- Self Employed
Qualifications*
Last Employer*
Last Employer*
Current Employer*
Office Address*
Street Address City State / Province / Region Country
Office Telephone*
Designation*
Annual Gross Salary*
ID (Int’l Passport/Drivers License/ National ID)*
Bank Name*
Account Number*
Residential Address*
Street Address Address Line 2 City State / Province / Region Country
Postal Address (if different from above)
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
Mobile Phone*
Email*
Name of Guarantor*
First Last
Guarantor's Address*
Street Address City State / Province / Region Country
Guarantor's Mobile Number*

Attestation
I, (Full Name)*
Prefix First Last
certify that all information contained in this document is accurate, complete and current as of date. I confirm that I have carefully read, understand and accept to be bound by terms and conditions set for the Financial Assistance Program before signing this attestation. I understand that the completion of this Form does not automatically guarantee the processing of my request and agree to notify Skills Farm of any material change that may affect my application as soon as the change occurs.
Name of Applicant*
First Last
Date*
Name of Witness*
Prefix First Last
Date*

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