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1215 Crossroads Blvd.

Norman, OK 73072 USA

Course Questionnaire
Phone: (405) 321-1383 Fax: (405) 321-4533

Exclusive provider of facilities training. www.jmcampbell.com
The information contained in this form will be used for internal purposes only. Contact ID: ________________________
First Name:_ _______________________________________ Middle Name: _ ______________________________________________
Surname: _ ________________________________________ Name You Like To Be Called: _____________________________________
Name as you wish it to appear on your certificate: _ ___________________________________________________________________
Job Title: ______________________________________________________________________________________________________

Company Name: _ ______________________________________________________________________________________________
Home or Work Address: __________________________________________________________________________________________
_____________________________________________________________________________________________________________
City: _ ____________________________________________ State/Province:_______________________________________________
Postal Code:_ ______________________________________ Country: ____________________________________________________
Work Phone: _______________________________________ Extension:___________________________________________________
Fax: ______________________________________________ E-mail:______________________________________________________
World Area: q North America q South America q Europe q Africa q Middle East q Southeast Asia/Oceania

Training Contact: _______________________________________________________________________________________________

Phone: _ __________________________________________ E-mail: _ ____________________________________________________

Immediate Supervisor: _ _________________________________________________________________________________________

Phone:____________________________________________ E-mail: _ ____________________________________________________

Emergency Contact: _ ___________________________________________________________________________________________

Phone: _ __________________________________________
Start Year at Current Position: _________________________ Number of years in the Industry: ________________________________
Education or Background and Discipline: _ __________________________________________________________________________
No Degree, Bachelor, Master, Doctorate / Chemical, Mechanical, Petroleum, Civil, Electrical, Operator, Maintenance

Professional Organizations I belong to: q AlChe q ASME q AIME q API q IEEE q OTC q SPE q Other, list below:
_____________________________________________________________________________________________________________
I am interested in: q Gas Processing q Pipeline/Transportation q Production Faciliites q Water and Corrosion
q Mechanical q Operations Management q Supply Chain Management q Reliability Engineering
q Offshore q Electrical and Instrumentation q Health/Safety/Environment q Refining

How did you hear about this course? q Campbell Web site q PetroSkills Website q Internet Search q Direct Mail
q Other _______________________ q E-mail q Friend/Co-worker q Training advisor q Supervisor
______________________________ q Oil and Gas Journal q Hydrocarbon Processing Magazine q Offshore Magazine

I would like to receive email regarding: q Updates on upcoming courses q Campbell Tip of the Month

Do you know anyone who could benefit from a Campbell course?

Name: _______________________________________________ E-mail: ___________________________________________________

What I would like to learn from this course: __________________________________________________________________________

_____________________________________________________________________________________________________________

My biggest challenge in the workplace is: ___________________________________________________________________________

_____________________________________________________________________________________________________________

Gas Processing | Pipeline | Electrical | Instrumentation | Offshore | Refining | HSE | Mechanical | Produced Water | Reliability