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Registration Form

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.  

Please Print:

Name:______________________________________ Employer:_______________________

                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: ________       

Signature: ___________________________________

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.