Please print and fill out the registration form and mail along with the tuition fee.  The tuition fee is the only way to guarantee a space for the desired course.  Cancellation two weeks prior to class will result in a full refund.  Cancellation one week prior to class will result in a $50 processing fee.  Cancellation within one week of class cannot be honored.  Leadtec reserves the right to cancel courses due to insufficient PAID enrollment.

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Name: _____________________________________________________________

 

Company: ___________________________________________________________

 

Address: ____________________________________________________________

 

City: ___________________________State: ______________  Zip: __________

 

Phone #_______________________  Fax #___________________   E-mail __________________________

 

Course Title*: __________________________________Course Date:____________

 * if you are signing up for a refresher course please provide the following information:

         Training Card Exp. Date ______________     MDE State Accreditation Exp. Date ______________

 

How would you like to receive confirmation for the course?

____Phone ____Fax ____Mail ____E-mail

 

Payment can be made by check, money order, or credit card (visa or master card)

 

Credit Card# __________________________________________ Exp: ________

 

Name on card: _________________________________

 

Security Code: (on back of card) _________________

 

Credit Card billing address: _____________________________________________

 

                                                   _____________________________________________

 

Mail to : Leadtec Services, Inc.

8841 Orchard Tree Lane, Baltimore MD  21286

 

Phone: (410) 321-7663      Fax: (410) 321-7666