FAX OR MAIL FOR ANY COURSE
REGISTRATION FORM
PLEASE PRINT:
Course Name ___________________________________________________________
Course Date ____________________________________________________________
Course Location _________________________________________________________
Course Price ____________________________________________________________
Name __________________________________________________________________
Position ________________________________________________________________
Institution Name __________________________________________________________
Institution Address ________________________________________________________
________________________________________________________________________
Home Address ____________________________________________________________
_________________________________________________________________________
W Phone (____)_______________________ H Phone (____)_______________________
Email Address ____________________________________________________________
Purchase Order #* ___________________________ Check # ______________________
*If you wish to use a Purchase Order, please request and complete the LSI Credit Application Form. Also Available at our website.
Credit Card # _____________________________________________________________
MC_____________ VISA_____________ Exp. Date ____________________________
Security Code (last 3 digits on back of the card)_________________________________
Signature ________________________________________________________________
RETURN TO:
The Laboratory Safety Institute
192 Worcester Road
Natick, MA 01760-2252
Phone: 800-647-1977 Fax: 508-647-0062