Member Training - Katie Beckett Attestation

Attention Employers of Record: If you represent more than one Member, please fill out an attestation for each of your Members. Fill out the form below and click submit. After you click submit, refresh the page and repeat for each Member.

Member Name

Member Name(Required)

Member CDTN Person ID

Member CDTN Person ID

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Member Birthday

Member Birthday(Required)

Member Email

Member Email(Required)

Member Last Four Digits of Social Security Number

Member Last Four Digits of Social Security Number(Required)

Select one option:

Select one option:(Required)

The member completed this attestation.

The member's Employer of Record (EOR)/Representative completed this attestation.

Employer of Record (EOR)/Representative Name

Employer of Record (EOR)/Representative Name(Required)

EOR/Representative Email

EOR/Representative Email(Required)

Signature
By signing, I attest that this training was completed solely by me.

Signature(Required)

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