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registration

REGISTRATION FORM

Please fax to: (305) 482- 9927		Phone #	305- 876- 1428
Mailing Address: 6992 N.W. 51st Street Miami, FL 33166
Hazmat Discount
Packaging, Inc
Student Name *
Supervisor Name *
Company Name *
Company Address *
Address (cont.)
City *
State/Province *
Zip/Postal Code *
Country *
Daytime Phone *
Evening Phone
FAX *
E-mail address *

Personnel Type: * (select applicable category)

Select Course:

QTY	Course Choice		Dates (MM/DD/YY)



Select Type of Billing:

Check or Money Order

Billing Address
(if different than above)

Indicate date of last training
(if recurrent course selected)

Will you be purchasing a 2010 IATA DGR? Yes No

Will you be purchasing a 2008 IMO/IMDG DGR? Yes No