CertificationZone Honor Roll Submission Form
Please print, complete and fax or mail this form along with your Cisco
Completion Certification to:

Genium Publishing Corporaton
1171 Riverfront Center
Amsterdam, NY 12010
Fax (518) 842-1843

First Name: _____________________________________

Last Name: ______________________________________

Address: _____________________________________________________

City: ____________________________ State: __________ Zip: ___________

Country: _________________________________________

Zone-ID: ___________________________________

Password: ____________________________________

E-mail Address: ____________________________________ (not for publication)

Phone number: _________________________________ (not for publication)

Fax number: ____________________________________ (not for publication)

Certification Earned (circle one):   CCNA / CCNP / CCIE

Do you want an e-mail reply box linked to your name at the site?   Yes / No

Comments (not for publication):



We will post your name on the CertificationZone Honor Roll within a few days. Your Honor Roll T-shirt will be mailed to you within two weeks (while supplies last).