Please complete the information below and submit online or return this form to:
HazTech Systems, Inc. P.O. Box 929, Mariposa, CA 95338 / fax (209) 966-8089 or training@hazcat.com
at least (6) weeks prior to course date. Use the attached Student Registration form to enroll individual students employed by your agency.
Please indicate payment method below (see COURSE Pricing). 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 .
Payment must be received prior to COURSE date. Make purchase order or check payable to: HazTech Systems, Inc.
Your Instructor will contact you two (2) to four (4) weeks prior to the COURSE date to confirm classroom arrangements. Please contact our office if you have any questions.
Company / Agency *
Phone *
Mailing Address *
Fax
City
State
Zip
Contact
Classroom Address
E-Mail
City
State
Zip
Course Date(s)
Industrial/WMD Refreshers – Call for information
S1702 - 2-Day – HazCat Awareness - $200.00
S1705 - 3-Day – Technician - $600.00
S1704 - 4-Day – Operations - $750.00
S1802 - 2-Day – WMD Awareness - $400.00
S1804 - 3-Day – WMD Technician - $600.00
S1805 - 4-Day – WMD - $750.00
S1803 - 5-Day – HazCat/WMD Operations - $900.00
S1901 - 5-Day – 4 HazCat/1 Meth - $900.00
● Dress Code for students: Appropriate long pants/slacks – No open toed sandals or shoes
Host Agency agrees to provide the following:
Tables & Chairs (individual student-type desks are not acceptable)
Cocktail style white napkins
Large wooden matches (1 box per station)
1 quart – distilled water
Small Coleman™ style propane cylinders (1 per station)
Classroom must be dedicated for the duration of the workshop and have:
Access to classroom at least 2 hours prior to class
Adequate ventilation with outside egress
At least 2 working fire extinguishers
HazTech Systems, Inc. may on occasion take photographs and/or video during training for use in print/electronic materials and/or quality control. If you wish to opt out of having photographs/videos taken during training, check the box.
Photos
COURSE PRICING
Purchase Order No
No. of Students
Check No
Date
Price per Student
Credit Card
Exp. Date
Sub-Total
Name as it appears on card
Title
Less Voucher Discount
Name: (Print)
Total Amt. Due
Signature
