Form 410 - State Of Hawaii Department Of Human Resources Development Sponsored Courses Human Resources Development (Hrd) Registration Form

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State of Hawaii
Department of Human Resources Development Sponsored Courses
Human Resources Development (HRD) Registration Form 410
Department’s Name: _______________________________________________________________________________
Course Title: _______________________________________
Course Date/Time: _______________________
Course Provider: ____________________________________
Course/Session #: ________________________
Course Location/Campus: ________________________________________
Fee: $___________________________
Instructions:
1) List only ONE class and session per form
2) List participants in order of priority
3) Send this registration form directly to the course provider or departmental personnel office ( if applicable)
4) Persons who have a need for auxiliary aids and services requests should note this on the Form 410 and submit
no later than 15 working days prior to the start of class
Name/s (Last, First, M.I.)
Email Address
Division
Phone No.
METHOD OF PAYMENT: Check one box and complete requested information
P-Card
P-Card Holder’s Name: _____________________________________________________________
P-Card Holder’s E-mail address : _____________________________________________
P-Card Holder’s Contact Phone Number: _______________________________________
P-Card Billing address: _____________________________________________________________
_____________________________________________________________
Check
Check#: __________________________________________________________________________
P.O.
PO#: ____________________________________________________________________________
I have determined that this training is appropriate for the person/s listed above.
Signature of Authorized Supervisor: _________________________________
Date: ________________________
Signature of Dept. Head or Authorized Rep: ___________________________
Date: ________________________
DHRD Form 410 rev. 8/2014

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