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REGISTRATION FOR CCMC FINAL  EXAM

NAME:  ______________________________________________

TOWN:  ______________________________________________

EMAIL: ______________________________________________

POSITION:  ___________________________________________

DATE OF HIRE:  _______________________________________

Check one:  _______ I have met the 3 yr experience requirement

                   _______  I have not yet met the 3 yr experience requirement, but wish to sit for the final written examination

ADDRESS WHERE EXAM RESULTS SHOULD BE SENT: 

________________________________________________________________

________________________________________________________________

By signing below, I, the applicant, hereby certify that I have successfully completed the written course of study by achieving a passing grade in each of the four qualifying courses; and that to the best of my knowledge and belief, I am eligible to be seated for the final written examination for certification as a Connecticut municipal tax collector under Conn. Gen. Stat. 12-130a.

If additional explanation is necessary concerning how you have met the experience requirement, please submit it with this application.

I / we understand that false or misleading statements on my / our part on this affidavit or otherwise will result in an unfavorable recommendation from the Certification Committee and may disqualify the applicant from consideration for Certification.

SIGNATURE OF APPLICANT:  _________________________________________

SIGNATURE OF APPLICANT’S SUPERVISOR:                             

                                                       _________________________________________

Date signed:  ___________________________  (deadline is June 1, 2009)

RETURN THIS FORM to: Lisa Biagiarelli, CCMC Tax Collector,

City of Norwalk, 125 East Avenue, Norwalk CT  06851,  or to   lbiagiar@norwalkct.org  NO LATER THAN JUNE 1, 2009.