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LS: VF-2010
Internet Block Registration Form
Company Name:
Company Phone: Ext #: Company fax:
Company Website Address: Contact E-Mail:
Company Contact Name: Contact Cell Phone:
Base Price Before Block Discount
40 Hour HAZWOPER: $565.00 / *$525.00 24 Hour HAZWOPER: $465.00 / *$425.00 8 Hour HAZWOPER Refr: $140.00/*$125.00 Site Supervisor: $235.00 / *$215.00
DOT: $235.00 / *$215.00 IATA: $235.00/*215.00 Dot Drug & Alcohol Supvr: $75.00/*$65.00 Defensive Driving: $59.95/*$49.95
EPA Haz Waste Mgmt: $595.00 / *$565.00 EPA Waste Mgmt Refr: $345.00 / *$295.00 Bloodborne Pathogens: $85.00 / *$75.00 HAZCOM: $69.95 /*59.95
Confined Space: $295.00/*275.00 Intro to OSHA: $75.00 / *$65.00 Forklift Safety/Powered Truck: $69.95/*59.95 H2S Hydrogen Sulfide Trng $59.95/*49.95
Lock-out/Tag-out: $69.95/* $59.95 Chemical Safety: $ 69.95/*$59.95 $$69.95/*$59.95
Respiratory Protection Trng: $69.95/*59.95 Other _______________ $ /
* When you pay at the time of registration you receive this price plus any block discounts!
Discounts for Block Registrations
5-10 Registrations 10% Discount 21-50 Registrations 25% Discount If you have more than 100 total registrations and you
11-20 Registrations 15% Discount 51-100 Registrations 45% Discount would like a quote. Please contact Victor at Ext. 318
Course Type: Number of Students: Standard Cost / Student: $ Discount Rate / Student: $
Course Type: Number of Students: Standard Cost / Student: $ Discount Rate / Student: $
Course Type: Number of Students: Standard Cost / Student $ Discount Rate / Student: $
Compliance Solutions offers 60 different courses online, for a complete listing visit our website at: www.csregs.com
Payment Method (Please Print)
Mail Check: *Check By Fax: Purchase Order (fax a copy with this form): Credit Card: Overnight Check:
Please charge my Credit Card: Visa: Master Card: AMEX: Discover:
Card Number: - - - Exp. Date: / CIC#: Amount: $
Name as it appears on the credit card:
Billing Address: City: State: Zip:
Cardholder’s Authorizing Signature: Today’s Date:
Note: Certificates will not be released unless full payment is received by the end of class, overdue balances will be assessed a 1.5% finance fee per month. Please refer to our cancellation/reschedule policies below.
Cancellation/Reschedule Policy: Unless you notify us in writing within 24 hours from the date you register, the following fees will apply:
1. All cancellations/reschedules will receive a 25% administrative fee if not cancelled within 24 hours of the registration date.
2. If your cancellation is made AFTER 24 hours from the time of registration or if you have completed more than 30 minutes of training, your tuition is NON-REFUNDABLE
3. All block licenses are non-refundable. Once a license has been used, the license cannot be transferred to another student under any circumstances. Licenses that are not
used within 365 days from the date of purchase are forfeited.
4. Registrations and licenses cannot be transferred to another student or used by another company or entity.
5. Online Block Registrants may choose to transfer to an Open Enrollment course (Some restrictions apply)
We care about your compliance status! In conjunction with registering the above student, you are authorizing us to keep you updated as to certification status and upcoming courses via fax and/or email and are
authorizing the sending of the same under 47 U.S.C. § 227. We occasionally send schedules to our clients and prospective clients but ONLY if they have given us prior permission to do so. If the person this
communication is directed to is no longer in your employ, please call us toll free with the proper contact or, if you wish to be excluded from this list, please call 1-800-404-2802 and we will insure you do not receive
future updates.

3980 Quebec Street, 2nd Floor, Denver, CO 80207 Phone: (800) 711-2706 Fax: (800) 511-4944 email: comments@csregs.com website: www.csregs.com