40 Boyd Street, Worcester, MA  01606 ·Phone: 800.939.7909 · Fax: 508.856-9280
Email: fixhybridacdc@yahoo.com Theresa Werth  Office Number is 508 963 1132
 

Name of Shop: ________________________________________________________________________ 

Street: __________________________________ City: ___________________ State: ___ Zip: _______

Name of Tech to take Hybrid Test _______________________________________________________ 

Shop Contact (one responsible for payment): _____________________________________________

Shop Phone (area code): (_____)______________       Fax number: (_____)______________

Must be ASE Certified in A1, A2, A6, A8, L1 for Qualified Tech Status   All 8 ASE plus L1 for Master Status  

If you live/ work in outside the USA, send an E mail to fixhybridacdc@yahoo.com

Where did you take the 8 hour ACDC Class?  Location _______________________________

What "Up Your Voltage!" Class were you enrolled into i.e #1 to #17 ___________________

Paying by Check
Please make checks out to ACDC for total charges & fees.
Mail check 40 Boyd Street, Worcester, MA 01606

I authorize my CC  for payment of the above fee

Sign here __________________________________________

Print name_________________________________________

Today's date   __________/_________/_________

If you fail the test, there is NO Refund Policy but you may retake the test 30 days later at NO additional fee. 

I understand the refund policy   ____________________________________________________