Asbestos Course Registration Form

2727 West 92nd Avenue, Suite 10 Denver, CO 80233 303.410.4941 140 West 29th Street, Suite 327 Pueblo, CO 81008 719.225.0283

Course Title: Course Date (s):

Student Name:
(Please print name, as you would like it to appear on the certificate.)

Student Name:
(Please print name, as you would like it to appear on the certificate.)

Student Name:
(Please print name, as you would like it to appear on the certificate.)

Employer: Contact:
Name Telephone Number

Mailing Address:

Street

City

State

Zip Code

Email

Payment Information
Enclosed is a check for $ VISA / MC / Discover
Card Number

Made payable to Colorado Hazard Control OR

Exp. Date CVV2#

Card Billing Address

City

State

Zip Code

In respect to all refresher courses, student has 2 years from the date of their last certificate to be eligible for a refresher course. Student is responsible for determining eligibility. Please provide copies of the most current refresher certificate when enrolling in a refresher course. There will be a $50.00 fee for cancelations received without 48 hours notice.

Fees:

Inspector Refresher: $100.00 Worker Refresher: $110.00 Project Designer Refresher: $155.00

Management Planner Refresher: $120.00 Contractor / Supervisor Refresher: $100.00 Colorado Air Monitoring Specialist Refresher: $120.00