Registration Form

Last Name:______________________________ First Name:______________________________

City/State/Zip:____________________________________________

Home Phone:________________ Work Phone:____________________

Place of Business:________________ Business Address:______________________________

E-mail Address:____________________

Emergency Contact              Name:________________ Phone Number:____________________

Disability accommodations needed     ___ Yes         ___ No

Course Title:............................Code:.....................Fee:..................Books:

____________________________ ___________________ _______________ ____________

____________________________ ___________________ _______________ ____________

Check or money order enclosed ___

Send the bill to my company ___
     Attach Letter of Employee's authorization (Must have prior Metro Technology Centers Approval)

VISA, Discover, Mastercard or American Express: ________________________________

Cardholder Name: __________________________________

Expiration Date: ___________________________________

How did you hear about Metro Tech?____________________