Registration Form

Accredited Academic Training

Instructed by Mitch Prather

Complete the form below and select the "Submit" button at the bottom of the form. A Registration Receipt, with a copy of the information submitted in the form and payment information, will be sent to the Student's Primary Email address, the Company Email address (if listed) and the Payment Method Email address (if applicable).

Note: Items indicated with an asterisk (*) are required.

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Courses/Workshops*:

Select One:

Student Information:

First Name*:

Last Name*:

Address*:

City*:

State*:

Zip Code*:

Cell Phone (format 916-555-1234):

Work Phone* (format 916-555-1234):

Work Phone Ext:

FAX (format 916-555-1234):

Primary Email*:

Re-enter Primary Email*:

Company Information:

Company Name:

Address:

City:

State:

Zip:

Phone (format 916-555-1234):

FAX (format 916-555-1234):

Email:

Payment Method*:

Invoice - Select this option to receive an invoice via email. You may pay the invoice online with a credit card or by mailing in a check.

Email Address:

Re-enter Email Address:

PO Number (if Applicable):

Comment:

PayPal - Select this option to pay onilne with a credit card or electronic check, using PayPal. If you select this option, you will receive an email with instructions for submitting the PayPal payment.