Registration Form

Complete the registration form and return with payment to:

Proactive Food Safety Training

PO Box 1892

Etowah, NC 28729

foodsafetycs@mindspring.com

Contact Person/Title:________________________________________________________

Company:________________________________________________________________

Address:_________________________________________________________________

City/State/Zip_____________________________________________________________

Phone/Fax:_______________________________________________________________

Email:___________________________________________________________________

Attendees:

(Note: make copies of this form for additional attendees)

Name:__________________________________________________________________

Name:__________________________________________________________________

Dates of class you are registering for: September 8-9, 2008

Class Location: Duke Energy Registration Fee:________________________

Type of book/exam you need and quantity:

English_______Spanish________Mandarin Chinese_________

¨ Check here if you would like your book mailed to you before the class. We are using the ServSafe Essentials 5^th Edition book only. Please add $6.00 per book (books will not be mailed without the added fee).

· The cost of this class is $170/person. Make checks payable to: Cynthia Scherbaty - PFST

· PFST has the right to reschedule the class. You will receive a full refund if the new dates do not work for your schedule.

· To certify as many attendees as possible, you must cancel 10 days prior to class or you will be required to pay a $50.00 re-registration fee for another class.

· For information on how to register on site, please call 704-591-3112.

· If you are re-testing, you must complete a new course registration form and return it with a $50.00 course registration fee.

· If you have your own book, the class fee is $100.00.