ASNT Level III Refresher Course Registration Form Jan/Feb 2014

E-mail Last Name Company Name Mailing Address ASNT ID First Name

City Zip/Postal Code Phone

State Country Fax

Courses NDT Basic Ultrasonic (UT) Magnetic Particle (MT) Radiography (RT) Liquid Penetrant (PT) Registration Deadline Cancellation/Transfer Deadline

Days 5 3 2 3 2

CEUs 4.0 2.4 1.6 2.4 1.6

Tuition $1500 $900 $600 $900 $600

Jan/Feb 2014 Course Dates

(Circle dates you plan to attend)

Amount

January 27-31 February 3-5 February 6-7 February 10-12 February 13-14 December 6, 2013 January 14, 2014 Total: $

Payment Information_______________________________________________________________
Form of Payment Type of Card Account Number AmEx Personal MasterCard Business Visa Discover Check Funds Transfer

________________________________________________Exp. Date______________CIN*___________

Name on Card (Please Print) ______________________________________________________________________________________ Signature Cardholder Information Billing E-mail address ______________________________________________________________________________________ ______________________________________________________________________________________
Address, City, State, Zip, Country

______________________________________________________________________________________

*Credit Card Identification Number. For Visa/MasterCard/Discover: The three-digit value is printed on the signature panel on the back of cards immediately following the account number. For American Express: 4 digit, non-embossed number printed above your account number on the face of your card.

Payment must accompany this registration form. Forms received without payment will not be processed. ASNT will accept checks, money orders, Visa, MasterCard, Discover, or American Express. Purchase orders are not acceptable. All foreign payments to ASNT must be made in U.S. currency drawn from a U.S. bank. Make checks and money orders payable to ASNT. Registration Policies: Class size is limited. Registrations are processed on a first come, first serve basis. Registered students who notify ASNT in writing of transfers or cancellations by the deadline listed below will be subject to a $100 cancellation/transfer fee per method. Transferred courses must be taken within one calendar year of original payment. There are no cancellations or transfers after the cancellation/transfer deadline. ASNT reserves the right to cancel any course. If ASNT cancels a course, a full refund of tuition is available or tuition may be applied to future courses or other ASNT programs. Please do not make hotel and travel arrangements until you have received an official confirmation of registration from ASNT.
For credit card payments fax to: 614.274.6899 For all other payments mail to: ASNT, 1711 Arlingate Lane, Columbus, OH USA 432280518