For the printable version of this form, click here. Deadline: Applications must be received 60 days prior to the examination date. Late Application: Late Fees apply when Applications are received less than 60 days (but not less than 30 days) prior to the examination date, and accepted only if space is available. Deferral: Requests to defer to the next exam must be received at least 30 days prior to the exam date. Contact the CCLS Certifying Board Chair at CCLScertifyingBoard@gmail.com for request to defer application. LSI MEMBERSNON-LSI MEMBERS Exam Registration Fee$25$75 Examination Fee$100$100 Total Application fee:$125$175 Partial Retake fee:$60$70 Deferral fee:$45$45 Region*Northern CaliforniaSouthern CaliforniaDateSaturday, September 21, 2019Saturday, March 21, 2020 Personal Information Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Last 4 digits of SSN*Email* Phone (Day)*Phone (Evening)*LSI MemberYesNoName of Local LSI Association Employment Information Provide your legal secretarial employment information beginning with your most recent (or current) employment in order to confirm that you have at least two years’ experience. Attach a supplemental page if you have not been in your current position for two years. Supplemental page uploadPosition*Dates of Employment*Employer (Name and Address)*Supervisor*Supervisor's Phone*Supervisor's Email* Summary of Duties*Certification* I agree I certify that I have completed this application truthfully. I understand that a false statement may result in the rejection of this application or revocation of my certification. I understand and agree that the contents of the examination are confidential and not to be discussed with anyone, and that my employment record will be verified by a member of the California Certified Legal Secretary Certifying Board.* Fees subject to change without notice. Upon approval of your application, you will be billed for the exam.