SkillTech Pre-Registration Name*: First Middle Last Gender: Male Female Date of Birth (mm-dd-yyyy) *: Address *: City *: State*: Zip *: Email: * Phone (xxx-xxx-xxxx) Home* Mobile Work Select all courses for which you are registering:*: Health Care LNA Extended Training Program (Tue & Thurs) $1350.00 Starts on 10/10/2017 Radiology for Dental Assistants $495.00 Starts on 10/14/2017 Welding Intermediate Basic Welding $320.00 Starts on 11/20/2017 Basic Welding $320.00 Starts on 10/09/2017 Facilities Operations Fundamentals of Natural Gas (required for State of Vermont Certification) $580.00 Starts on 09/18/2017 Refrigerant Transition and Recovery Certification $630.00 Starts on 10/10/2017 Natural Gas Recertification (Vermont) $180.00 Starts on 10/07/2017 Billing Information Who is paying for this course?* Myself/Student Employer VSAC Other Please specify: (Please include name of organization paying, name of the person who can authorize payment, and phone/email of that person) If Employer will be paying for your course(s) please provide following information: Employer Name: Employee Address: City: State: Zip: Authorized by (name): Authorizer Phone: Authorizer Email: Payment Information Method of Payment:* Cash/Check Make checks payable to Center for Technology, Essex Mailing Address: SkillTech at CTE, attn: Linda Whitaker 2 Educational Drive, Suite 200 Essex Junction, VT 05452 Purchase Order Credit Card If paying by credit card, please call 802-879-5559. We do not collect or stpre credit card information online. (Mastercard or Visa only) Other Please specify: As a confirmation: *: Write this security code All dates, times, prices, discounts and class listings are subject to change. Once you submit this form, you will be pre-registered for your course. Registration will not be complete until payment is received.