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Education Benefit Seminar Request Form

Complete chapter contact and seminar request information below. A chapter coordinator will contact you shortly.

* Required Fields DO NOT HIT ENTER
CONTACT INFORMATION
* Chapter Name:	*
* Name:	*
* Address 1: (no PO boxes, please)	*
Address 2: (no PO boxes, please)
* City:	*
* State:	*
* Zip Code:	*
* Phone:	*
Fax:
* E-mail:	*
SHIPPING ADDRESS
SAME AS ABOVE? (if not, please complete below) *
Chapter Name:
Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone:
Fax:
Special instructions:
BILLING INFORMATION
Same as contact information above
Same as shipping information above
Other:
EDUCATION BENEFIT(S)
Request for our chapter's education benefit seminar:
Online Onsite On the phone
Title of seminar:
Date of seminar:
Location of seminar:	(City, State)
Site Phone Number:
Anticipated # of participants:
Preferred instructor:
Indicate your desired schedule: Seminar Sample Schedule Start: 8:00 am Break: 10:00 am Lunch: 12 Noon End: 3:00 pm Break: 1:30 pm	Start: AM PM End: AM PM Lunch: AM PM Break 1: AM PM Break 2: AM PM
Will you allow non-chapter members to attend seminar?: YES NO
If yes, can we post this seminar on the iccsafe.org website?: YES NO
EDUCATION BENEFIT(S)
Request for a carry-over chapter education benefit seminar:
Online Onsite On the phone
Title of seminar:
Date of seminar:
Location of seminar:	(City, State)
Site Phone Number:
Anticipated # of participants:
Preferred instructor:
Indicate your desired schedule: Seminar Sample Schedule Start: 8:00 am Break: 10:00 am Lunch: 12 Noon End: 3:00 pm Break: 1:30 pm	Start: AM PM End: AM PM Lunch: AM PM Break 1: AM PM Break 2: AM PM
Will you allow non-chapter members to attend seminar?: YES NO
If yes, can we post this seminar on the iccsafe.org website?: YES NO
EDUCATION BENEFIT(S)
Contract with ICC to provide a seminar(s) in conjunction with chapter seminar(s) :
Online Onsite On the phone
Title of seminar:
Date of seminar:
Location of seminar:	(City, State)
Site Phone Number:
Anticipated # of participants:
Preferred instructor:
Indicate your desired schedule: Seminar Sample Schedule Start: 8:00 am Break: 10:00 am Lunch: 12 Noon End: 3:00 pm Break: 1:30 pm	Start: AM PM End: AM PM Lunch: AM PM Break 1: AM PM Break 2: AM PM
Will you allow non-chapter members to attend seminar?: YES NO
If yes, can we post this seminar on the iccsafe.org website?: YES NO
*Note:* A carry-over education benefit seminar from the previous year may be used consecutively and/or the chapter may contract for additional training days. Please provide the appropriate information above for each seminar requested. A minimum of 30 participants is required each day in order to use your chapter education benefit or carry-over education benefit seminar.
SUBMIT


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