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"Take a step in the right direction" SM
Jonathan Klane
M.S.Ed., CIH, CHMM, CET


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KEITH SM
93 Norridgewock Road
Fairfield, Maine 04937
(207) 453-KEITH (5348)
Fax (207) 453-5226

 



Course Registration Form
 

Course name:
Course date:
Course location:
Course cost:
Registrant’s name:
Registrant’s
DOB or SSN *:

( * We would prefer not to get this info, however, the Maine DEP requires either a date of birth (DOB) or social security number (SSN) for the certificate. If you have taken a course with us before, odds are we have it. If you prefer to call us at (207) 453-5348 with the info, please feel free to do so).

Company/
Organization/
Sponsor name:
Address:
 
 
City State Zip
Phone:
Fax:
E-mail:

Training Disclaimer:
By enrolling in and/or attending this class, you acknowledge that you have the correct prerequisite for the course (such as the same initial course as the refresher course) or if not, you will not be applying for state, federal, or tribal certification. Also, as a training course, discussions including those of the instructor are understood to be only for the purposes of education and learning examples and are not intended as, nor should be taken as, health and safety recommendations (tacit or otherwise). The student is solely responsible for ensuring that class discussions are not inappropriately applied to situations outside of class discussions and must verify any information prior to relying upon it at one’s own liability.

I accept 

Cancellation Policy:
Please note that we are planning on your attendance financially. If you cannot attend due to unforeseen circumstances, please inform us not less than 3 business days in advance. Otherwise, no refund can be made. You may send a substitute from your organization. We reserve the right to cancel the class due to insufficient registrations or other unforeseen circumstances and will refund in full.

I accept 

Payment Policy:
We do not accept payment from individuals – only from their employer (includes a self-employed person’s company check), organization, or sponsor. Payment is expected prior to the course. Thank you!

I accept

           


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