CHIP Test Registration

You are about to register for the CHIP Test scheduled on: December 14, 2019

Test Fee: $75.00

Not the date you're looking for? Go back to testing schedule

Personal Information: (All fields are required)

First Name

Last Name

Email Address

Date of Birth

Gender
Male Female

Cell Number

Text Alerts
Receive text alerts regarding my scheduled test

Driver's License Number

Driver's License State

Emergency Contact: (All fields are required)

First Name	Last Name
Phone	Relationship To You

Payment Details: Test Fee: $75.00

Credit Card Number

Expiration Date

CVV What's this?

Name on Card

Address

City

State

Zip

Receive emails regarding upcoming tests

I agree to the Terms of Registration.
and that a Medical Approval Form must be signed and brought to the CHIP Test.
By opting to receive text alerts regarding your scheduled test, you also agree to the SMS Terms & Conditions.