CONTRACTORS EDUCATIONAL SERVICES REGISTRATION FORM

NAME:   

COMPANY:   

 CONTRACTOR LICENSE#:  

ADDRESS:       

CITY:   

STATE:

ZIP:

EMAIL:

PHONE:

FAX:

CHOOSE ONE:

__Course A&B 2-Day Seminar (14hrs)  $209       City\Dates____________________

__Course A only (7hrs-day one)    $115               City\Date_____________________

__Course B only (7hrs-day two)     $115               City\Date_____________________

TO REGISTER

CALL (941) 924-5825 OR

  FAX FORM TO 941-924-7843

Method of Payment: AMEX_____ DISC______M/C_______VISA_______CHECK_____

 Credit Card #_____________________________ExpDate_____________________________

 (if paying with Discover last 3 digits on back of card)__________________________________

Credit Card Authorization Signature_______________________________________________

By Check : Mail payable to Contractors Educational Services, 5293 Ashley Parkway, Sarasota, FL 34241