BACKFLOW TESTER TRAINING REGISTRATION FORM
Choose one of the following options:
Backflow Assembly Tester Refresher Training $200 Please provide the following attendee information:
Backflow Assembly Tester Refresher Training $200
Please provide the following attendee information:
Student Name Student Name Student Name Student Name Student Name Organization Street Address Address (cont.) City State/Province Zip/Postal Code Country Work Phone FAX E-mail
Choose one of the following event options:
January 24 - 25, 2008 Phoenix Classroom March 06 - 07, 2008 Phoenix Classroom May 08 - 09, 2008 Phoenix Classroom July 10 - 11, 2008 Phoenix Classroom August 07 - 08, 2008 Flagstaff Arizona September 04 - 05, 2008 Phoenix Classroom December 04 - 05, 2008 Phoenix Classroom
January 24 - 25, 2008 Phoenix Classroom March 06 - 07, 2008 Phoenix Classroom
May 08 - 09, 2008 Phoenix Classroom
July 10 - 11, 2008 Phoenix Classroom
August 07 - 08, 2008 Flagstaff Arizona
September 04 - 05, 2008 Phoenix Classroom
December 04 - 05, 2008 Phoenix Classroom
Please provide the following Payment information:
BILLING
Purchase Order #
Account Name
If you will be paying by check please remit payment to:
Cross Connection Environmental
1802 S Carson Street Suite 212-2783
Carson City, Nevada 89701
Students will not be fully registered until payment is received.
Card Type Visa Master Card Discover American Express Credit Card Number Expiration Date Name of Cardholder Billing Address City State Zipcode Number of Students Email Address for Receipt Credit card information is recorded to a secure server. Information not transmitted over internet.
Credit card information is recorded to a secure server. Information not transmitted over internet.
Terms and Conditions