REGISTRATION FORM - RESPIRATOR TRAINING

Name and Title________________________________________________________

Company_______________________________________________________________

Street________________________________________________________________

CITY, STATE/ZIP_______________________________________________________

Phone_________________________________________________________________

FAX___________________________________________________________________

EMAIL_________________________________________________________________

Home Phone____________________________________________________________

Course Date and Location_____________ Location  ________________________

Type of Respirator Currently Used:(if known)__________________________

Fit Testing Procedure Employed:_______________________________________


Please call our office if you plan to bring your own equipment on which to be trained.

Registration Fee: $495 Due 2 weeks prior to course. No refunds but transferable.

Please send a check along with this registration form

Mail To:
Palmer Associates Inc.

1840 41st Ave Suite 102-258

Capitola, CA, 95010

Phone: (831) 239 0422

FAX: (831) 462-5652

Make checks payable to: Palmer Associates Inc.