COURSE REGISTRATION

 

Registration form and payment must be received at least 1 week prior to the class.  A confirmation will be sent upon receipt of a completed registration form and payment.  Preferred method of confirmation:  ______email  ______phone

 

Name of Course:___________________________________________ Date:_________________

 

For all Mold Classes, please check the appropriate description below:

 

Mold Initial: (Check one) ___Assessor ___Remediation Contractor ___Worker

Mold Refresher: (Check one) ___Assessor ___Remediation Contractor ___Worker Supervisor ___Worker

 

STUDENT INFORMATION:

 

Name:_____________________________________________________ NYS DMV ID__________________________

                                                                                                                                             (Required for all mold courses)

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    ____American Express ____Discover ____Visa ____MasterCard

 

I, ______________________________hereby authorize HSE Consulting Services LLC to charge my credit card account

in the amount of  $________ (quoted price) for the above-referenced training.

 

Credit Card Number:_________________________________ Card Holder Name:_______________________________

 

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:________________________

 

8636 Brewerton Road

Cicero, New York 13039

 

Safety / Industrial Hygiene

Air Quality / Asbestos / Lead / Mold

OSHA Compliance / Training

Environmental Services

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Ph # (315) 698-1438

Fax # (315) 698-1441

www.hseconsultingservices.com