ENROLLMENT
FORM - Course #313
Last
Chance For The Exec™-
Maneuvering, Troubleshooting,
and Data Organizing™
COURSE
PRICE:
$250.00
| Cash:
Yes___ No____ |
Amount
Paid :______________/Date:_____________ |
| Check:
Bank_____
Personal____ Business____ |
Check
# :____________________ |
DL#____________________ (optional) |
Expiration____________ |
State:_________ |
| Credit
Card Used (selct one): Visa:________________/Exp:_________ MC:
________________/Exp:__________
Discover:________________/Exp: _________
JCB:________________/Exp:__________
Debit (Visa)___________________/Exp:____________
Debit (MC)_____________________/Exp______________
( CVV_______ ) |
| P.O.
#:_______________________________________________________________ |
Gift
Certificate #:_______________________________________________________ |
DATE: ____________________
TOTAL AMOUNT AUTHORIZED: $____________________
AUTHORIZED SIGNATURE
FOR AMOUNT PAYMENT METHOD USED (i.e., Credit Card, Check,
PO# ):_______________________________________________________________________
I
AGREE TO PAY THE ABOVE TOTAL AMOUNT ACCORDING TO THE CARD
ISSUER AGREEMENT FOR THE ABOVE LISTED CREDIT CARD and/or
FOR THE PURCHASE NUMBER (PO#) LISTED ABOVE. ALL
SALES ARE FINAL. NO REFUNDS. I AGREE
TO ALL GUIDELINES, POLICIES, AND PROCEDURES OF COMMBASE
TECHNICAL SOLUTIONS, LLC PRIOR TO ANY COURSE ATTENDANCE.
Course Date
Selected:___________ Course Date Scheduled:___________
Class/Receipt Confirmation:____________________
Attendee Confirmed :____________
STUDENT NAME:___________________________________
ADDRESS:_______________________________________
TELEPHONE#:_________________________
CELL#:______________________
FAX#:_________________________
E-MAIL:_________________________________
COMPANY NAME: _______________________________________ADDRESS:______________________________________
TELEPHONE#:__________________________
CELL#:______________________
FAX#:__________________________
E-MAIL:_________________________________
(Internal
Use Only)
Payment
& Registration Processed:
Fax Order_____ Telephone Order_____
e-Commerce_____
Marketing
Rep ID#:______________________ Telephone/Cell#:____________
/____________ Email:____________________
Course#:____________
Date Completed:_______________ Approved
Spiff/ID#:_________________
CommBase
Technical Solutions, LLC |
Attn: Training Department |
PO Box 82143 * Las Vegas, NV * 89189 |
Tel: (307) 773-0124 / (702) 785-7720, ext. 1003 * Fax: (702) 947-6713 * Email: enroll@compbasetraining.com |
