enrollment form

Enrollment Form
Student Information
^{First Name:}	^{Last Name:}
^Title:
^Company:
^{Mailing Address:}
^City:	^State:	^Zip:
^{Daytime phone:}	^{Evening phone:}	^FAX:
^E-mail:	Check here if you need a receipt mailed to you:
^{Preferred User ID}:	^{Preferred Password:}
*Payment Information*
Mail this completed form along with a check payable to International Laboratory Supply, and which covers the course costs to: International Laboratory Supply PO Box 130549 The Woodlands, TX 77393-0549 FAX: 281-298-9410
Course Information
Indicate the course in which you are enrolling: Select your objectives for taking this course: Learn new information Professional development Meet corporate training specifications CEUs/training hours to maintain professional certification. Please ensure such is offered in your state for the course you select (check the accreditation summary and provide operator number or other information as required by your State). Other:
*User Agreement*
By affixing my signature below, I understand that this enrollment form provides enrollment in the course noted above for myself only, and that use of course exercises, activities, assignments, or any other course materials by others is strictly prohibited. I further understand that copyright laws apply to the use of all materials that will be found in the course, with the exception as noted for public domain publications, and that violation of these copyright laws subjects me to severe civil and criminal penalties for unauthorized reproduction or distribution of this course, or any portion of it, and these violations will be prosecuted to the greatest extent possible under the law. Sign Name and Date:
*Other Information/Special Requests*
How did you hear about us/special requests?
A Welcome Packet including your user ID and password will be forwarded by e-mail within 24 hours of enrollment processing. Thank you for choosing Environmental Training at YOUR Convenience!