INTERDISCIPLINARY EARLY CHILDHOOD EDUCATION
Registration Form
(To register: Please print, complete, and mail this registration form along with your CERTIFIED/CASHIER’S CHECK or MONEY ORDER to the address below.)

NAME:______________________________________________________________________________
LAST
FIRST
MIDDLE

SSN: _________________________ DATE OF BIRTH:________________________ GENDER: ________

HOME ADDRESS:______________________________________________________________________

CITY:____________________________________ STATE: ____________ ZIP _____________________

E-MAIL ADDRESS:______________________________________________________________________

HOME PHONE (______)______________________ WORK PHONE (______)______________________

Place an "X" beside your choice.
REGISTRATION FORM AND PAYMENT MUST BE RECEIVED BY THE DEADLINE.
PLEASE ALLOW ADEQUATE TIME FOR YOUR PAYMENT TO REACH US.

2004 Test Dates
2005 Test Dates
____ July 17, 2004 [DEADLINE JULY 1, 2004]
 _____ January 22, 2005 [DEADLINE JAN 7, 2005]
____ Oct 16, 2004 [DEADLINE SEPT 30, 2004]
_____ April 23, 2005 [DEADLINE APRIL 8, 2005]
_____ July 16, 2005 [DEADLINE JULY 1, 2005]
_____ October 15, 2005 [DEADLINE SEPT 30, 2005]

Place an "X" beside your choice.

____ Campbellsville University ____ Murray State University
____ Eastern Kentucky University ____ Northern Kentucky University
____ Western Kentucky University ____ Pikeville College
____ Morehead State University ____ University of Louisville
____ Union College  

Mail this completed form and a $55.00 CERTIFIED CHECK/CASHIER’S CHECK OR MONEY ORDER
made payable to the KENTUCKY STATE TREASURER to:

Jaime Rice
Education Proffessional Standards Board
100 Airport Rd., 3rd Floor
Frankfort, KY 40601

Examinees will receive written confirmation and further details by mail. If you have questions, please
contact Jaime Rice by phone at (502) 564-4606 or toll free at (888) 598-7667 or by e-mail at
Jaime.rice@ky.gov.

Note: Information provided on this form may be shared with your University test site.