Please mail or fax your completed form to
Government Training, LLC.
COR 40hrs – (40 CLPs)
Level II – Certification/Re-Certification
Registration/Payments Processing
ATTN: David C. Dickson
20842 Derrydale Sq. Sterling, VA, 20165
Training Workshop Registration
Phone: 703-622-1187, Fax: 941-870-9651
[email protected]
Feel free to make copies of this form for additional attendees
Attendee Information
Payment Details
Name:
Check Payable to:
Company/Agency:
Credit Card:
Government Training, LLC.
Tax-ID: 27-0799412
American Express
Address:
Mastercard
City:
Discover
Visa
State:
Zip Code:
Card Number:
Main Contact:
Expiration Date:
Email:
Security Code:
Phone:
Cardholder Name:
Billing Address:
Registration Fee (5 day course)
Signature
Government: $1,095.00
Corporate: $1,095.00
Please specify the date you are registering for
Month
Date
Year
IMPORTANT: Open Enrollment Training Terms and Conditions
Airline Tickets: It is recommended that you do not make non-refundable airline reservations – There are sometime circumstances out of our control
(weather, natural disaster, other emergency situations) that would cause us to postpone our scheduled course.
It is the responsibility of the registrant to check our website for any last minute changes that may have occurred concerning our training
BEFORE departing for the class. Last minute changes are posted as soon as possible. – Go to www.GovernmentTrainingInc.com for more information
or contact [email protected]
I have read and agree to the terms of Cancellation policy above.