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Diplomat Fee Payment

This form should be used to pay the Diplomat fee only. An application form must be requested from Dr. Herndon and materials must be submitted by mail. For more information about diplomat procedures and requirements click here.

Please complete all information. If you wish to pay by credit card, fill in the application below and click on the "To Pay By Credit Card" button below. The form will be electronically submitted and you will be transferred to a secure server to give your credit card information.

If you wish to send in a check, please PRINT this form, fill it out and send it to the address below with the appropriate fee(s).

Name
Last, First, M.I.

Business Address:

Home Address:

Do you prefer information to be sent to your:

Home address, or

Office address?

Business Phone:
Home Phone:
Fax:
Email Address:

Diplomat Application Fee: $375 (non-refundable)

If you want to mail a check, send it with your application form to:

James S. Herndon, Ph.D., Ed.D
P.O. Box 540296
Orlando, FL 32854