Health & Safety Services
Electronic Course Registration

This Electronic Course Registration form will allow you to register for Health & Safety Services Courses VIA the internet. Please complete all the appropriate data fields then click on the submit icon to register for the desired course.

 
To use this Electronic Course Registration you must use either a Master Card or VISA credit card to pay for the course fee.

If you do not have a credit card, you are required to pre-register in person at the Tallahassee office of the Capital Area Chapter. 

Date:
Name:

Work Phone Number:

Mobile Phone Number:

Home Phone Number:

Primary E-Mail Address:
(* Required)

Secondary E-Mail Address

Street Address

City / State / Zip

Credit Card
   Master Card
   VISA
Credit Card Number

Credit Card Expiration Date

First Course Selection Date
/ Time / Location

Second Course Selection
Date / Time / Location

      

Return To: Health & Safety Services Training

Last Update: