Please fill out the form below so that we can verify your certification information.

Upon receipt our Seminar Coordinator will call you to verify your Student's programs and process payment.

Fields marked with a red asterisk (*) are required.

Your First Name:
Your Last Name:
Company Name:
Email Address:	(E-mail)
Phone Number:
Best Time to Call:	anytime morning afternoon
Date of Class: Class Schedules: 2009 | 2010
Location of Class:
Type of Certification:
Student 1:	First Name:
	Last Name:
	Phone Number:
	Certification Number: -
	Expiration Date of Current Card (click button to the right of field to select date):
Student 2:	First Name:
	Last Name:
	Phone Number:
	Certification Number: -
	Expiration Date of Current Card (click button to the right of field to select date):
Student 3:	First Name:
	Last Name:
	Phone Number:
	Certification Number: -
	Expiration Date of Current Card (click button to the right of field to select date):
Student 4:	First Name:
	Last Name:
	Phone Number:
	Certification Number: -
	Expiration Date of Current Card (click button to the right of field to select date):
Student 5:	First Name:
	Last Name:
	Phone Number:
	Certification Number: -
	Expiration Date of Current Card (click button to the right of field to select date):
Type the characters you see in the picture below.

If you need recertification for more than one, hold down the Ctrl key and highlight all the classes you are recertifying for.

When complete, please submit your form so we can verify your certification information. We will contact you within 24 hours.