Register for a Course

Registrant Name *

As you would like to appear on certificate

Company Name

License No. *

Street Address *

Street Address Line 2

City *

State *

Zip Code *

Cell No. *

Area Code Phone Number

Your Email *

Years of Experience *

Designation
OTPTCOTAPTACHTATCOther

Employment *

  • Registration confirmed when we receive your check. Check must be received before Oct 8th
  • Print registration and mail to Ashim Bakshi – 619 E. Springhill Drive, Terre Haute, IN 47802
  • Early bird registration ends Oct 8th. $385
  • If you register with another person, please mail both application with the checks together. The per person price when registering with other people is $360/ Person
  • Early Bird ends Oct 8th and the price increases to $425