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

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.

Host Agency Information

COURSE Information

HazCat Classes:

WMD & Combo Classes

● 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.

Minimum number of paid students 12 . Please pay student tuition in full. When enclosing payment, please include discount of one free seat for voucher redemption.