COURSE REGISTRATION

 

Please mail or fax (315-698-1441) registration form.  A confirmation will be sent upon receipt of a completed registration form and payment.  Preferred method of confirmation:  ______email  ______phone

 

Name of Course:___________________________________________ Date:_________________

 

Course Location: ________________________________________________________________

 

STUDENT INFORMATION:

 

Name:_________________________________________

 

Address:_____________________________________________________________________________

 

Phone:________________________________ email:_________________________________________

 

COMPANY INFORMATION:

 

Company Name:_______________________________________________________________________

 

Address:_____________________________________________________________________________

 

Contact Person:__________________________________ Phone Number:_________________________

 

CHECKS Payable to:  HSE Consulting Services, LLC - Mail to:  8636 Brewerton Road, Cicero, NY 13039

 

Check #___________   Amount:______________  Date Mailed:________________

 

CREDIT CARD PAYMENTS     CARD TYPE:   _______ American Express______ Visa      ______ MasterCard

 

I, __________________________________ hereby authorize HSE Consulting Services LLC to charge my credit

 

card account in the amount of  $__________ (quoted price) for _________________________________________

 

Credit Card Number:______________________________________________________

 

Card Holder Name:___________________________________ Phone #_________________________

 

Card Holder Address:_________________________________________________________________

 

Expiration Date:______      Security Code (3 digits on back of card for MC & Visa, 4 digits on front for AX):_____

 

Card Holder Signature:____________________________________ Date:____________

 

ALL INFORMATION ON THIS FORM WILL BE KEPT CONFIDENTIAL

REFUND/CANCELLATION POLICY:  Refunds will be issued to students in the event HSE Consulting Services, LLC (HSE) must cancel the scheduled class and/or if student gives one (1) week notice of cancellation.  If student gives less than one (1) week notice of cancellation, credit will be given towards the next available class.  Refunds will not be given for any student that does not cancel their registration or begins a class and is unable to complete the entire class.  

Student Signature_______________________________________________ Date:___________________________

Air Quality

Asbestos / Lead / Mold

OSHA Compliance / Training

Environmental Services