CertTEC Work Verification Form for Recertification

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To request recertification, please complete and submit this form to CertTEC.
Section A should be completed by the person requestingrecertification.
Section B should be completed by the person validating work verification
(i.e., Supervisor, Manager, or Human ResourcesRepresentative).
Information on how to submit form and payment is located in Section C.

All fields must be completed for Recertification request to be processed

Section A

Date of this submission

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Personal Phone

Business Phone

Personal (home) E-mail Address:

Company/Organization

Job Title

List Certifications to Recertify

Section B

The following section to be completed by person providing work verification
(Supervisor, Manager, or Human Resource Representative)

Name

First

Last

Company/Organization

Job Title:

Business Phone

Section C

Cost:
$10 for electronic version of certificate sent by email
$25 for hard copy of certificate and/or ID card sent by mail

Completed form and check payment can be submitted to:
SpaceTEC Partners, Inc.
379 Cheney Hwy.
PMB 207
Titusville, FL.32780

If paying through PayPal: Scan and email form to info@certtec.com
PayPal payments can be made at:
https://spacetec.us/certtec-recertification-payment-form

Any questions, please contact CertTEC staff at (321) 567-5193

The following section to be completed by CertTEC staff.

Layout

Date form received and record updated:

Form verified by:

Payment amount:

Method of payment:

**All fields must be completed for Recertification request to be processed**