Please fill in the registration form below. We will send you a confirmation of enrollment after receipt of this form.

Company Name
Address
City	State
	Select State Alabama Alaska American Samoa Arizona Arkanasas California Colorado Conneticut Deleware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersy New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconson Wyoming AF Africa AF Americas AF Canada AF Europe AF Middle East AFs Pacific
Zip	Phone
Fax	Email
Student Name
Street Address
City	State
	Select State Alabama Alaska American Samoa Arizona Arkanasas California Colorado Conneticut Deleware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersy New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconson Wyoming AF Africa AF Americas AF Canada AF Europe AF Middle East AFs Pacific
Zip	Phone
Fax	Email
Course Information - Please select course and course dates: Backflow Prevention Technician 40 Hours: $585.00 Backflow Prevention Technician Recertification (Texas license renewal)* 32 Hours: $485.00
Dates for Albuquerque, NM
- May 12 - 16 July 14 - 18 40 Hour Course
- May 12 - 15 July 14 - 17 32 Hour Course
Method of Payment: Check or Credit Card
We accept:
Please select Credit Card - Mastercard Visa (We will contact you for card information)
Puchase Order No.
"*Payment must be received on or before the 1st day of class*"

Hours: 40 $585.00
2008 DATES:
May 12 - 16
July 14 - 18
Hours: 32 $485.00 *
May 12 - 15
July 14 - 17

* TEXAS STUDENTS ONLY:
* Requires new TCEQ application plus check to TCEQ for $105.00

Day 1 - 4 qualifies for TCEQ recertification.