Retirement Request Form

Name

Today’s Date

Email Address

All communications with certificants will be made via email. Please be sure to enter your email address correctly.

Mailing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Are you looking to retire your CCM or CDMS credential?

Certificate Number

Certificate Expiration Date

Retirement Attestation

I attest that I will not be providing consulting or other services in the future using my CCM/CDMS certification while in CCM-R or CDMS-R status.

I understand if my retirement status changes and if I wish to regain use of the CCM or CDMS certification, I will need to meet the criteria in effect at the time of reinstatement including, earning all Continuing Education credits and Ethics requirements, in addition to paying the renewal fee at the time of reinstatement or re-take the exam.

I further understand that retirement status is only good for five years. At the end of the five-year cycle those that have chosen the retirement designation have the option to renew as a “retired CCM/CDMS” or renew as a “CCM/CDMS” per the guidelines in the associated Renewal Guide.

Printed Name

Date

Signature

At the end of the five-year cycle, those that have chosen the retirement designation have the option to renew as a “retired CCM/CDMS” or renew as a “CCM/CDMS”. To keep the retirement status, you are required to pay a fee of $100 every five years and fill out this required form. You will be notified by a Certification Coordinator within 2 weeks after your request is submitted.

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