Training Registration Form THIS INFORMATION IS FOR YOUR CERTIFICATE AND STATE AHERA RECORDS Last Name: First Name: Middle Initial: Last 4 Social Security #: Signature (type name): Email Address: Yes, send me Email renewal notices and other safety training related information HOME INFORMATION Address: City: State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: Phone (include area code): Cell (include area code): WORK INFORMATION Company Name: Address: City: State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: Phone (include area code): Fax (include area code): Position: CLASS INFORMATION Class: Instructor: Date(s) of Class: PAYMENT INFORMATION Payment is Due Prior To Time of Class: $125.00 Full Day $75.00 Half Day Payment Method(s): Cash Check Charge There is a 2-person minimum attendance. Those who register will be notified the day before class if the class does not meet the 2-person minimum attendance requirement and if the person still wishes to attend the class an additional fee of $50 per 1⁄2 day or per day will be charged. A fee of $50.00 will be charged for cancellations less than 24 hours before class or no shows.
