Trainee Information.........

Name__________________________________ Current Date__________________

 

Social Security # __ __ __ - __ __- __ __ __ __ Date of Birth __________________

 

Company Name (if applicable) ____________________________________________

 

Work Address: ___________________________________________________________________

 

Home Address:___________________________________________________________________

 

Work Phone ( ) ___________________ Fax ( ) _________________________

 

Home Phone ( ) ___________________ email _____________ _________________________

 

Attending......

 

Course Name ____________________________________ Date(s) of Course ________________

Course Name ____________________________________ Date(s) of Course ________________

Course Name ____________________________________ Date(s) of Course ________________

 

Payment Information..... (To reserve a place in the course, one of the following forms of payment is required)

 

1. Charge my tuition to Visa ____ MasterCard ___ American Express _______

Credit Card Number ________________________________ Expiration Date _____________

Cardholder’s Name _________________________ Signature _____________________________

             Cardholder’s Billing Address __________________________________ Zip_________________

 

2. Prepayment:  $ ___________ enclosed check or money order

 

3. Purchase Order: PO# __________________________ Authorized Signature __________________

 

Important Registration Information......

 

-For Refresher courses, trainee must bring prior initial training and all refresher certificates if we do not have them on file.

-Students who drop out voluntarily are subject to payment of half the cost of the course or can register for the same course again at no additional cost.

 

Registrant Signature__________________________________________________________