Training Registration Form

*Course Name

*Date/Location

*Student's Name

*Title

*Additional Students

*Employer

*Employer's Address

*City

*Zip

*Work Phone

*Work Fax

*E-mail Address

Cell phone**
After Hours Emergency

*Lunch

Check here, if staying for lunch.

*CreditCard

MasterCard Visa

Card Number

Exp. Date

Security Code:
(last 3 digits on signature strip)

Voucher Number

Comments

**We value your privacy, and we would only use this number in case the instructor has a last minute emergency, that would prevent us from holding the seminar. Listing the Number is optional.

CLAIMENTS CERTIFICATION & DECLARATION
I do solemnly declare and certify under the penalty of the law that the within bill is correct in all its particulars, the articles have been furnished or services rendered as stated herein, that no bonus has been given or received by any person or persons within knowledge of this claimant in connection with the above claim and that the mount charged is a reasonable one.

Just send your check with the application form! You do not need to send us your voucher for a separate signature since the pre-signed certification on the left can be attached to your voucher in the lieu of sending it to us for a signature. This form has been determined by the DLGS to meet the requirements of the statutes for the type of expenditure.

Anne McNally, VP