INSTRUCTOR CERTIFICATION REGISTRATION FORM

							   INSTRUCTOR CERTIFICATION REGISTRATION FORM
Print your name exactly as you would like it to appear on your certificate.

Title:          ___________________________________________
First Name:     ___________________________________________                   MI: ________
Last Name:      ___________________________________________
Social Security Number (Student ID): ________________________


Agency:         ___________________________________________
Address:        ___________________________________________
City:           ___________________________________________
State:          ___________________________________________                   Zip: ________
Phone:          ___________________________________________
Fax:            ___________________________________________


Home Add:       ___________________________________________
City:           ___________________________________________
State:          ___________________________________________                   Zip: _________
Home Phone: ___________________________________________                       Fax: _________
E-mail:         ___________________________________________

Location
Of Course:      ___________________________________________
Course Date: ___________________________________________                      Fee: $150.00

             Payment Method:               Check Enclosed               Credit Card
                               (Please circle which ever applies.)
Credit Card #: _________________________________________ Exp.: ______________
Name as it appears on card: ______________________________            Security Code: ______
Address to which the credit card is billed: ________________________________________
City: __________________________              State: ______________           Zip: ________

Mail To:        Security Equipment Corporation       Or Fax:         636-343-1318
                747 Sun Park Drive
                Fenton, MO 63026