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Training Registration Form

THIS INFORMATION IS FOR YOUR CERTIFICATE AND STATE AHERA RECORDS

Last Name:
First Name:
Middle Initial:
Last 4 Social Security #: 
Signature (type name):
Email Address:
  Yes, send me Email renewal notices and other safety training related information
 
HOME INFORMATION
Address:
City:
State:
Zip Code:
Phone (include area code):
Cell (include area code):
 
WORK INFORMATION
Company Name:
Address:
City:
State:
Zip Code:
Phone (include area code):
Fax (include area code):
Position:
 
CLASS INFORMATION
Class:
Instructor:
Date(s) of Class:
 
PAYMENT INFORMATION
Payment is Due Prior To Time of Class:
  $125.00 Full Day
  $75.00 Half Day
Payment Method(s):
  Cash
  Check
  Charge
 
There is a 2-person minimum attendance. Those who register will be notified the day before class if the class does not meet the 2-person minimum attendance requirement and if the person still wishes to attend the class an additional fee of $50 per 1⁄2 day or per day will be charged.

A fee of $50.00 will be charged for cancellations less than 24 hours before class or no shows.