OTI 502 - Update for Construction Industry Outreach Trainers

Registration Form
(Items in Red are required fields)

First Name
Last Name
Degrees
Prof. Title
Gender	Male Female
E-mail
Home Phone
Work Phone
Fax

Company
Department
Address
Address2
City
State
Zip
Country

ADA Describe Any Disabilities
Are You Vegetarian?
List Any Food Allergies

At which OTI Education Center did you complete your last trainer course?:

Trainer Number

IMPORTANT: Please provide a copy of your current authorized trainer card and the prerequisite form to the USF OTI Education Center via fax to 813-994-1173. If you do not provide a copy before the course or bring it with you to the course a new card/certificate will not be issued until one is on file with the USF OTI Education Center Office. Please note that your card must not be more than 90 days expired. If the card is more than 90 days expired you will need to retake the trainer course (500 for Construction) to remain active. If you do not have your card please contact the education center where you took the course for a copy or a letter stating that you are an authorized trainer and what your expiration date is.

DISCOUNT CODE: (only one discount code can be used per course)
Notes/Comments

Registration Dates, Locations and Fees

Please check which course you are registering for.

Course Registration: $600

	Location	Start Date	End Date
2010
	Tampa, FL	March 30	April 01
	Miami, FL Courtyard by Marriott 200 Se 2nd Ave Miami, FL 33131	April 26	April 28
	Jacksonville, FL	May 03	May 05
	Orlando, FL	June 08	June 10
	Tampa/Wesley Chapel, FL	July 26	July 28
	West Palm Beach, FL	August 23	August 25
	Orlando, FL	September 27	September 29
	Tampa/Wesley Chapel, FL	October 18	October 20
	Daytona Beach, FL	November 01	November 03
	Fort Myers, FL	November 08	November 10
	Orlando, FL	December 13	December 15

Payment Method
(Note: You will not be charged until registration is confirmed.)

Cancellation Policy
Cancellation notification must be in writing (FAX or email are acceptable). A cancellation fee equal to 25% will be assessed. Written cancellations received less than 5 working days prior to the event will be charged the cancellation fee plus the per-person cost. No-shows will be billed. Substitutes are welcome without penalty.

The Continuing Professional Education Office at the University of South Florida Health Sciences Center reserves the right to cancel this activity due to unforeseen circumstances. In the event of such cancellation, only the registration fee will be returned to the registrant.

Credit Card

	Mastercard
	Visa
	American Express

Name (exactly as on card)
Credit Card Number
Expiration Date (mm/yy)
CVC Code

Check

Please make checks payable to:

USF HPCC
PO Box 864240
Orlando, FL 32886-4240

On your check, please include the program code which is printed on your confirmation and the registrants name or a copy of the registration.

Bill Later For Registrations Paid By PO

PO Number


If billing address is different than above - please list below
Company
Attn:
Address
City	State	Zip
Phone EMAIL

Security Notice

Accommodations for Disabilities: Please notify the CME Office, 12901 Bruce B. Downs Blvd., MDC Box 60, Tampa, Florida, 33612 or call (813) 974-6695 a minimum of ten working days in advance of the event if a reasonable accommodation for a disability is needed.

Events, activities and facilities of the University of South Florida are available without regard to race, color, sex, national origin, disability, age, or Vietnam veteran status as provided by law and in accordance with the University's respect for personal dignity.