Registration – American Institute of Technical Education

Prefix

First Name

Middle Name

Last Name

Email *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Home Phone Number

Cell Phone Number

Date Of Birth

Course Name

All ModuleYesNo

If No, Module #

Course Start Date

Payment Method

Select

Amount

USD

Check #

Amount

USD

Name on the card

Credit Card #

Expiration Date

Last 3 digit

Name of the card

Billing Adress CC

State Id (License) #

State where Id Issued

In Case of Emergency, please contact

Name

Phone No (W)

Relationship

Office Loc

Do you have a medical condition or are you taking medication on a regular basis that would be important to know in case of an emergency?YesNo

If yes, please explain

I agree to give a testimonial, if this training helped me secure a job/placement.YesNo

Date

Disclaimer: Refund policy - No refund after half a day class. Any future dispute need to be resolved with the InstituteUSA ONLY.

**If above Candidate (Card holder or the training attendee) continue the class after Demo session followed by half session of first day, the candidate will be
responsible for the fee with the fact that cost is associated with number of attendee. If the candidate is not happy with the class, S/he can re-take the NEXT
class but in any case NO Refund will be provided. Email confirmation will be used as the signature of card holder.

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