California Online Enrollment

CALIFORNIA 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
*Preferred Mailing Address:

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:

California CDPH Courses

Worker - English Course	$395
Worker - Spanish Course	$395
Continuing Education for Workers - English	$95
Continuing Education for Workers-Spanish	$95
Supplemental Supervision/Project Monitoring	$275
Inspector/Assessor	$675
General Continuing Education	$135
Sample Technician	$135
EPA Renovator, Repair, & Repainting Initial	$175
EPA Renovator, Repair, & Repainting Refresher	$95

AHERA Courses

Building Inspector Refresher	$75*
Management Planner Refresher	$75*
Project Designer Refresher	$135
Contractor/ Supervisor Refresher	$125
Worker Refresher	$95
Worker Initial	$450

**If both Building Inspector Refresher (8am-12pm) and Management Planner (1pm-5pm) are taken the same day, then the combined cost for both classes will only be $125.

Adult CPR/First Aid

$125

Total amount from course selection(s):

For more information: training@allstate-services.com

Or call (800) 497-5323