APPLICATION FOR MEDIA CERTIFICATION

Yes! I want to become certified by the Society To Advance Media Professionalism. I have met the preliminary requirements of experience and character and hereby make application to become a:

 Certified Media Generalist - Exam Fee: $375
 Certified Broadcast Media Buyer - Exam Fee: $275
 Certified Print Planner / Buyer - Exam Fee: $275


Name: ______________________________________________ Phone: (____) _________________
Title: _______________________________________________ Fax: (____) ____________________
Company: ___________________________________________ E-Mail: _______________________
Address: ____________________________________________ Number of Years In Media: _______
City: ________________________________________________ ST: ________ Zip: ______________
Brief Resume: ______________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

I plan to take the exam on (date) ______________________________________________________.
The exam will be proctored by (name) _________________________, (title) __________________.
Exam material should be sent to the proctor at:
Company: ___________________________________________ Phone: (____) _________________
Address: ____________________________________________ Fax: (____) ____________________
City: ________________________________________________ ST: __________ Zip: ____________


Applicant Signature: ____________________________________________ Date: _______________

Return this application with appropriate examination fees to:

S.T.A.M.P. Certification
297 Oakmont Close
Westminster, MD 21158