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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
   
Click submit to process. Please wait.
     
 

 

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