REGISTRATION FORM

CROSS--CONNECTION CONTROL & BACKFLOW PREVENTION SCHOOL

Please Print:

NAME:______________________________________________________________________________

^{First
Middle Last}

HOME ADDRESS:_________________________________________________________________________

^{STREET CITY STATE ZIP}

COMPANY: ________________________________________________POSITION:__________________________

BUSINESS:____________________________________________________________________________________

^{STREET
CITY
                                STATE                   ZIP}

PHONE: (_____) -________ -________ (______) ______ - _________ (______) _______- ______

^{Home
WORK
EXT.
fax}

E-mail____________________________________________________

Refunded only if class is canceled or 2 weeks notice prior to start date

WORKSHOP $400.00 00. ASSE. Test $200.00

Re-Certification Class--$275.00 Includes ASSE Test.

Full Certification

Re-Certification Current Certification #_______________ Expiration date ________________

STARTING DATE OF CLASS REGISTERING FOR: DATE: ______________ DAY______ EVENING____

ENCLOSED FIND: ( ) full payment ( ) purchases order#_________________

CREDIT CARD: Master card Visa

Account # ___________ ______________ ___________ ________________ Expiration Date:_____/_______

Card holder Name. ___________________________________________________________

Signature: __________________________________________________

ASSE requires 5 years of experience in a Plumbing related field. Pleas list your experience below. Use additional sheets if needed.

__________________________________________________________________________________

_______________________________________________________________________________

IF YOU ARE ON THIS WEB SITE PLEASE FILL OUT THE WEB APPLICATION

INSTEAD OF PRINTING AND FAXING THIS APPLICATION PDF FORM

MAKE CHECKS PAYABLE TO: MAIL TO:

S & M Water Consultants S & M Water Consultants
4980 Topaz Dr.
Colorado Springs, CO. 80918