FAX OR MAIL 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 __________________________

Signature _______________________________________________________________________  

RETURN TO:

The Laboratory Safety Institute

192 Worcester Road

Natick, MA 01760-2252

Phone: 800-647-1977      Fax: 508-647-0062