Print and Return by Mail or Fax
Please register at least three days before the start of the workshop.
If class is scheduled for two or more sessions, please plan to attend all sessions. Class materials will be provided during the first session. If you have any questions, please call us at 231-348-6613 or 231-348-6705.
Registration/Cancellations: Keep a copy of this registration form. If a class is cancelled, we will contact you using the phone number or e-mail you provide below. If a class is cancelled, or if you cancel before the start of the class, North Central will issue a full refund.
Last First MI
Home Street Address City State Zip Code
( )_____________________ Birth Date:_____/______/19____SSN* _______/____/______
Daytime Telephone Month Day Year * required for CEU certification
E-mail address ____________________
Have you attended North Central before? ____No ___ Yes, my Student Number is:__________
1) Course title: ___________________ Date/s: __________Location: __________Amount: $__________
2) Course title: __________________ Date/s: __________ Location: __________Amount: $___________
3) Course title: _________________ Date/s:__________ Location: __________Amount: $___________
4) Course title: ________________ Date/s: _________ Location: __________Amount: $___________
5) Course title: __________________ Date/s: __________ Location: __________Amount: $___________
10% discount (if signing up for 2 or more one-day workshops) Less $ ___________
Discount does not apply to long-term or online training.
Total Amount Enclosed: $_______________
( ) Check (made out to NCMC-CCE) or money order for full amount
( ) Invoice employer (please attach purchase order from employer on separate sheet)
( ) Credit Card (complete section below)
( ) VISA ( ) MasterCard ( ) Discover
CC Number:_____________________________________ Exp. Date: ________
Mail completed form to: CCE/NCMC, 1515 Howard Street, Petoskey, MI 49770
or Fax to: 231-348-6705
Keep a copy of this form for your records.