MSP - Application (only) to Register for 2008-09 CBRNE/WMD, Hazmat, and Tech Rescue Courses

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Application (only) to Register for 2008-09 CBRNE/WMD, Hazmat, and Tech Rescue Courses

APPLICATION INSTRUCTIONS

1. Do NOT complete this application in the Printer Friendly version - we will not receive your application form.

2. Complete this application.

3. Print a copy of the application, using your browser printer, before submitting your application for your records.

4. If you are paying by credit card, be sure to scroll down to the "Credit Card Payment" form before submitting this application. Complete the form, sign it, and then fax it to 517-322-6442 for processing. No credit card payments will be processed until acceptance letters are mailed.

5. All other applicants will receive invoices with their acceptance letters. Please note: Do NOT try to pay your invoices with a credit card. Pay your invoices only with a check or money order.

6. Submit your application using the "Submit" button at the bottom of the page.

COURSE NAME:

STUDENT INFORMATION:
First Name:
M.I.:
Last Name:
Job Title:
Last 4 digits of Social Security Number:
Organization:
County of Organization:
Organization Mailing Address:
City:
State: Zip:
Country:
County of Residence:
Business Phone:
Ext:
Business Fax (Required):
Home Phone:
Mobile Phone:
Email Address (Required):
Discipline:
If Other, please list:

Check if applicable:
Private Industry

If Governmental:
Local
State
Federal

Who is registering this student?
Self
Other: (name, title, and phone number)

Organization Contact (name and phone number for mailing purposes/questions):

BILLING: Who is responsible for the payment of this course? (Required):
Student
*Employer--- Purchase Order Number:
Other:

*If the Employer is responsible, is he/she aware of your attendance? (Required)
Yes

LODGING:
Please select one of the three lodging options.

I DO NOT require lodging.

Double occupancy lodging. (Will be arranged by the EMHSTC.)

Single occupancy lodging. PLEASE NOTE Single lodging is neither provided nor billed by the EMHSTC. You may check this box and be added to our list so you receive our government rate; however, you will be responsible for paying your share of the single lodging at the hotel.

I will require lodging for the following nights:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Smoking
Non-smoking

(Required)
Male
Female

TERMS AND CONDITIONS

EMHSTC COURSES

Applications are accepted on a first-come, first-served basis.

Students will receive a letter of acceptance approximately 21 days prior to the first day of the course.

Cancellation of attendance shall occur 7 working days before the training course begins. Failure to cancel or "No Shows" will be charged the full training amount. Reservations are transferable within a department or organization.

Students may not be allowed to participate in a program if their registration fee has not been paid by the first day of the program. Payments using a credit card may be made during the registration process; all others will receive an invoice with their letters of acceptance.

All students must meet the course prerequisites and the medical surveillance requirements set forth by MIOSHA and NFPA 471 in order to be accepted.

EMHSTC course costs include student materials, morning and afternoon refreshments, lunch, and double occupancy lodging if pertinent to the course.

Lodging - Double occupancy lodging is included in course fees as specified.   Arrangements will be made by the EMHSTC as indicated on the student application. Students may make private arrangements of their choice at their own expense. Be sure to indicate your lodging needs on the application. If your lodging needs change from that indicated on your original application, you must contact the Training Center within 7 days of the course or you will be responsible for the entire cost of lodging.

I have read and agree to all enrollment terms and conditions. (Required Field)

Please print all pages before you submit your application.
Acceptance letters will be mailed approximately three weeks before the course.

ALL INCOMPLETE APPLICATIONS WILL BE DENIED

CREDIT CARD PAYMENT


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•	2008-2009 Training Course List
•	Application (only) to Register for 2008-09 Emergency Management Pem Courses