Member Training - Katie Beckett Attestation

Employer of Record (EOR)/Representative Name
Employer of Record (EOR)/Representative Name(Required)
Member Name
Member Name(Required)
Member CDTN Person ID
Second Member Name (If Applicable)
Second Member Name (If Applicable)
Second Member CDTN Person ID (If Applicable)
EOR/Representative Email
EOR/Representative Birthday
EOR/Representative Birthday(Required)
EOR/Representative Last Four Digits of Social Security Number
EOR/Representative CDTN Person ID
EOR/Representative Signature
By signing, I attest that this training was completed solely by me.