First Name *
Last Name *
Address *
City *
State *
Phone *
Company *
E-Mail *
Business Address *
City *
State *
Zip *
Mobile Phone
How did you hear about this workshop?
Registration Information
If registering more than one (1) student, please make copies of this form and complete separate registration information for each student. You may however, combine payment information on a single registration form. Registration deadline is six (6) weeks prior to workshop date. Call for late registration information. Please indicate payment method below. If purchase order is used, you will be invoiced. If check or credit card payment is used, you will receive an invoice marked paid in full. Make purchase order / check payable to: HazTech Systems,™ Inc. Submit registration form(s) to HazTech Systems,™ Inc. P.O. Box 929, Mariposa, CA 95338. ٭ Dress Code for Students: (appropriate long pants/slacks – closed toe shoes)
Workshop location *
Workshop Date *
No. Of Students
Voucher Serial No (1 Free workshop voucher valid after sending in Warranty Card)
Purchase Order No
Check No
Credit Card
(Expiration Date)
Cvv (short code on the back of card)
(Type)
(Name as it appears on card)
Payment must be received six weeks prior to workshop date. Call for late registration information. Make check or purchase order payable to: HazTech Systems™, Inc. P.O. Box 929 – Mariposa, CA 95338
I PLAN TO ATTEND
HazCat classes
S1702 - 2-Day – HazCat Awareness $400.00
S1705 - 3-Day – Technician $600.00
Refresher - Call for information
S1804 - 3-Day – WMD Technician $600.00
S1805 - 4-Day – WMD $750.00
S1901 - 5-Day – 4 HazCat/1 Meth $900.00
S1803 - 5-Day – HazCat/WMD Operations $900.00
S1802 - 2-Day – WMD Awareness $400.00
Amount Due: $
