REGISTRATION FORM - The Siemon Company



2012 REGISTRATION FORM

Please complete the registration form below and fax it to:

Program Support Services

The Siemon Company

Telephone (860) 945-4200 Fax (860) 945-8516

Registration Policy - A $100.00 registration fee per attendee is required. This fee will be applied towards the cost of the class. Cancellations must be made 14 business days prior to the course date. If the cancellation is made after that, the registration fee is not refundable. An equally qualified substitute is welcome with no cancellation fee.

Name: Title:

Company:

Address:

City, State, Zip:

Telephone: Fax:

E-Mail:_________________________________

Attendee Prerequisites - The purpose of the Siemon Certified Installer Training Class is to teach the requirements and recommendations of the Siemon Cabling System for the purpose of registering qualified installations for a Siemon Cabling System Warranty. The attendees of the training should possess a good knowledge of cabling system design and/or cabling system installation and be knowledgeable of current telecommunications standards. Attendees should also possess practical telecommunications experience and have a minimum of 3 years experience in either the design or installation of telecommunications systems. This training is not meant for telecommunication industry novices. By registering for the Siemon Certified Installer class you have confirmed that you meet the prerequisites as indicated above.

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Please select a class (Seats are limited - please register as soon as possible)

___June 26-28 Atlanta, GA ___July 17-19 Minneapolis, MN

___August 7-9 Watertown, CT ___August 21-23 Southern CA

___September 11-13 Las Vegas, NV

More classes to follow….

Course Fee: $750.00 (for Connecticut classes add 6.35% sales tax) *Does not include travel, room, or meals.

Payment method:

If Paying by Credit Card: Cardholders Name (Print)___________________________________

Cardholders Signature______________________________________

MasterCard, Card number - ____________________________________ Exp. Date

VISA, Card number - __________ Exp. Date

___Check Enclosed (Number)____________________

IS-1831-04 Rev 5/3/12

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