BACKFLOW TESTER REFRESHER REGISTRATION FORM

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
Tester Number
Work Phone
FAX
E-mail

           Choose one of the following event options:

January 27 - 28, 2011     Phoenix Classroom
March 10 - 11, 2011      Phoenix Classroom

May 05 - 06, 2011         Phoenix Classroom

 July 28 - 29, 2011         Phoenix Classroom FULL

September 22 - 23, 2011     Phoenix Classroom

November 03 - 04, 2011    Phoenix Classroom

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CCENV NOW REQUIRES A FORM OF PAYMENT BE DECLARED BEFORE WORK IS STARTED

 

          Please provide the following Payment information:

If you will be paying by check please remit payment to:

Cross Connection Environmental

1802 S Carson Street Suite 108-2783

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.

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