Demonstration site-class-registration-form

Demonstration site-class-registration-form

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  Ozark Soils, Sinkholes,and Onsite Troubleshooting at the Onsite Wastewater Training Site in Springfield, Missouri Date: May 18, 2012 Time: 8:00 a.m.— 4:00 p.m. Check in begins at 7:30 a.m. Light breakfast refreshments provided by Table Rock Lake Water Quality Lunch provided by Missouri Smallflows Organization Cost: $20 per person (Anticipated 4-5 CEUs, pending approval) Registration required by May 15 (confirmations will be sent via email) Location: C.W. Titus Education Facility at the Watershed Center 2450 E. Valley Water Mill Road, Springfield, MO Directions: See second page Please detach this portion of the form and send to the Missouri Smallflows Office with registration payment. Name: ______________________________________ Address: _____________________________________________________________________ Phone Number: __________________________ Email Address: __________________________________________________________________ Confirmations will be sent by email. State License Numbers Installer #_______ Inspector #_________ OSE #__________ Perc Tester #______ Send registration form and check Add a $5 convenience fee for all credit card payments via mail or fax credit card □ Check here if card billing address same as above payment to: Card #: ____________________________________________ Missouri Smallflows Organization P. O. Box 606 Exp: ___/____ CVV: ________ Kimberling City, MO 65686 Name on Card: ____________________________________ Phone: (417)739-4100 Fax: (417)739-9889 Card Billing Street Address: _________________________ Email: [email protected] Card Billing ZIP code: _______________________ Website: www.mosmallflows.org