Arizona Online Enrollment

ARIZONA ONLINE ENROLLMENT

Please complete the following form. All areas marked with an " * " are required.

Please provide the following personal information:

*First Name
Middle Initial/Name
*Last Name
*Home Address
Home Address (cont.)
City, State, *Zip

Please provide the following company information:

*Employer
*Street Address
*Address (cont.)
*City, State, Zip
*Phone Number
Fax Number
*Email Address
Billing Address
Billing Address (cont.)
City, State, Zip

Please provide the following billing information:

*	*Card Number
* Expires	*Cardholder

A card number is required to hold your place in your class. Your card will not be billed until you attend the class. You may bring a check for payment. If you do not cancel your enrollment and do not attend class, your card will be billed the full amount.

Select the courses you wish to attend:

EPA-ACCREDITED LEAD COURSES

Inspector*	$535
Risk Assessor*	$360
Supervisor	$695
Worker	$390
Renovation, Repair, and Repainting	$175

*The inspector is a prerequisite for the risk assessor.

Select the refresher courses you wish to attend:

EPA Lead Worker	$185
EPA Lead Supervisor	$185
EPA Lead Risk Assessor	$185
EPA Lead Inspector	$185
EPA Renovation, Repair, and Repainting	$95

Total amount from course selection(s):

For more information: training@allstate-services.com

Or call (800) 497-5323