Registration Form - Chem Scope, Inc.

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Chem Scope, Inc.
15 Moulthrop Street,
North Haven CT 06473-3686
Registration Form
Phone (203) 865-5605
version 11/13
Fax (203) 498-1610
Trainee Information.........
Name________________________________________________________ Current Date__________________
Social Security # _X_ _X_ _X_ - _X_ _X_- __ __ __ __
Date of Birth __________________
Company Name (if applicable) ________________________________________________________________
Street Address: _____________________________________________________________________________
Street Address #2: __________________________________________________________________________
City/Town______________________________________ State_________ Zip Code_______________________
e-mail ______________________________________________________________________________________
EMAIL Policy: By providing Chem Scope, Inc. with your email address you are giving permission for Chem Scope, Inc. to email you information
regarding up coming training classes.
Work Phone
(
) _________________________ Fax (
) ________________________________
Home Phone
(
) ________________________ Cell (
) _________________________________
Attending......
Course Name _______________________________________________ Date(s) of Course ________________
Course Name _______________________________________________ Date(s) of Course ________________
Course Name _______________________________________________ Date(s) of Course ________________
Payment Information.....
Pre-Payment is Required
Charge my tuition to my Credit Card (three options):
1. Call the office with credit card information, 203-865-5605 or
2. Fill out Credit card processing form page 5 of Training Course Catalog and fax to 203-498-1610 or email to
chem.scope@snet.net
3. Bring credit card information on day of class and pay at the office
Or: Send a check or Money Order with the Registration Form to Address above
Important Registration Information......
-For Refresher courses, trainee must bring prior initial training and all refresher certificates if
we do not have them on file.
-Classes Start at 8:00 AM (Sharp) unless otherwise noted
-Classes at Chem Scope are held at 8 Moulthrop Street, North Haven CT 06473 (Red Building)
Registrant Signature_____________________________________________________
NAS (scott)myfiles/MSPUB/Training/Trnreg1210.pub
Page 4
203-865-5605 •

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