IDenticard Customers

IDenticard University Learning Center

Course Registration Form
for Web-Based Customer Classes

Company Name:

Today's Date:

E-mail Address:

Account #:

Address Line 1:

City, State

Zip Code:

Telephone Number:

Fax Number:

1st Course Name:

Date(s):

2nd Course Name:

Date(s):

Name(s) of Attendee(s):

Cost:

(Please call for course names and costs: 800-233-0298)

Payment:
(check one)

Purchase Order (Please provide #)

P.O. Number:

Charge my Credit Card (VISA or MasterCard) Provide information below:

* Account Number:

Exp. Date:

Cardholder's Name:

Please print this form and fax it to: 717-569-2390

Questions? Please call: 1-800-233-0298

IDenticard Systems, Inc., Attn: Jill Yescalis, P.O. Box 5349, Lancaster, PA 17606-5349
E-mail: jill.yescalis@identicard.com

*Note: IDenticard reserves the right to cancel this class. Full refunds will be provided in this case.