Auto-Careers.org: Hybrid Training Resources Since 2000

Enrollment Form
40 Boyd Street, Worcester, MA 01606 ·Phone: 800.939.7909 · Fax: 508.856-9280 Email: Craig@ auto-careers.org· Craig Van Batenburg, AAM, CMAT, L1
Class & Tech Information
Class Name: ________________________________ Class Dates: _______________________________ Shop Name: ___________________________________________________________________________ Street: ___________________________________ City: ___________________ State: ___ Zip: _______ Name of Student #1 _________________________________________ Cell #: (_____)______________ Spouse / Partner #1____________________________________________________________________ Fee for Spouse / Partner (Includes meals) $__________ Make / Model of Scan tool bringing to class: ______________________________________________ Make / Model of Scope bringing to class: __________________________________________________ Shop Contact (one responsible for payment): _____________________________________________ Shop Phone (area code): (_____)______________ Fax number: (_____)______________ Paying by Check Please make checks out to ACDC for total charges & fees. Mail check 40 Boyd Street, Worcester, MA 01606
Credit Card Payments
Name On Card:	Visa MasterCard Discover	Exp: / /
Total Charges to Card:			$
Note: We will bill your CC in 4 payments if you prefer if signed up 4 months ahead. I authorize my CC for payment of the entire class E Mail _______________________@_________________________ Sign here __________________________________________ Print name_________________________________________ Today's date __________/_________/_________ Airline Information Name of Airline _________________________________ Must fly to Providence, R.I. NOT Boston Flight # ________________ Lands at Time: _______ pm on Thurs. Must land between 12-5 pm Flight # ________________ Takes off at Time: _______ pm on Mon. Must leave no earlier than 3pm Refunds Refund Policy: No refund 30 days before start of class. Full refund minus $195 non-refundable enrollment fee if canceled in writing 30 days ahead* or you can substitute another qualified person. I understand the refund policy ____________________________________________________

Use 1 form per tech/partner or spouse
Print & Fax form to 508 856-9280 (secure fax) or Email to Craig@auto-careers.org

Last Updated: 4/8/08