Certified Trainer Enrollment

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Certified Trainer Enrollment Form

Required Items. Please read the cancellation policies.

Student Information:
Student Name:
Student Email:
Agency Information:
* Agency:
Contact Name:
* Job Title:
* Phone:
Fax:
Address:
City:
State:	Zip:
Course Information:
Certification Cost:	$3995.00 per person (Cost includes all exams, courses and training materials)
*Choose area of certification:

Payment Method: NOTE: All certification programs must be paid in full before students are registered in the program. Once payment is received, students will be contacted with enrollment information, i.e. times, dates, course materials, examination requirements and login information. Travel expenses for courses are not included in the price listed above. Students are responsible for all travel expenses, i.e., hotel, airfare and per diem.
* Payment Method:	PO#:
	Please bill the company: letter of authorization or purchase order will be faxed to (901) 758-4036. I have read and understand the cancellation policies for HSU courses.
Card No:
Expiration Date:
Security Code:	(3-digit security code on back of card)
Name on Card:
Authorizing Manager:
Comments:
Payment Method:

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HSU provides a range of services to allow persons with disabilities to participate fully in educational programs and activities. If you desire support services, contact the student Access Center at (901) 758-4034.

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