REGISTRATION REGISTRATION REGISTRATION REGISTRATION FORM FORM FORM by KevinCrouthers

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									RAISING AWARENESS AND LIFTING STANDARDS

ABOUT YOUR COMPANY:
 Company: _________________________________________________ Type of Business: ______________________________________
Address: _______________________________________________ City: ___________________ Prov: _____ Postal Code: ___________
Phone: ______-________-____________ Ext.______       Cell: ______-_______-__________         Fax: _____-_____-_______
Contact Name: _________________________________ Email: ___________________________________________________________
Equipment used in your Environment: ( check all applicable)
     Counterbalance      Electric             Propane                Rough Terrain            Reach Truck       Order Picker
     Stacker             Low Lift Pallet Truck (Walkie/Rider )       Aerial Work Platform     Crane and Hoists
     Attachments (Specify)_____________________________              Other ___________________________________________________



                                                                         Participant Name(s): (please print)
REGISTER FOR A TRAINING PROGRAM: ( check one)
                                                                         (1) ___________________________________________
     1-Day Train-the-Trainer
     2-Day Train-the-Trainer                                             (2) ___________________________________________
     1-Day Train-the-Supervisor                                          (3) ___________________________________________
     1-Day Crane Train-the-Trainer
                                                                         (4) ___________________________________________
     1-Day CSA B335-04 Trainer Qualification Program
                                                                         Applicable Registration Fee:
                                                                         $_________.00 x _____ person(s) = $ __________.00
    Training Date:                                                                         Add 5% GST      $ __________.00
    Location:                                                                                 Total Due    $ __________.00
    Authorized Signature:                                                GST REGISTRATION #80410 1616 RT0001



                                                                        !"# $%&'' '!( ' &                 %!)!" *+
METHOD OF PAYMENT:
    Payment enclosed (Company Cheque or Money Order payable to Provincial Training Centre)
    Invoice: Purchase Order number or reference must be indicated here: ________________________________________

    Credit Card Payment:                         Visa               Master Card          Amex
    Name on card: ____________________________ Number: _______________________________ Exp Date: ____/____
    Signature of cardholder: __________________________________                 Date: _______________________________________
                                                                                        (MONTH)            (DAY)             (YEAR)


HOW TO REGISTER:                 By Fax:  905-625-8398
                                 By Mail: Provincial Training Centre, 2-3415 Dixie Rd., Ste. 224, Mississauga, ON L4Y 4J6
                                 Online:  www.provincialtraining.com

CONFIRMATION OF REGISTRATION:                      Upon receipt of your completed registration form by Provincial Training Centre,
confirmation and all program details will be emailed to the CONTACT PERSON named above.

CANCELLATION POLICY: Cancellation or request to reschedule must be received in writing and will be accepted without penalty
FIVE (5) BUSINESS DAYS or more prior to date of training. Cancellations will not be accepted after this period.

ENQUIRIES ON PROGRAM INFORMATION: Please call Provincial Training Centre at 905-625-1623.

								
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