Class Reservation Form

Name ________________________________________________________

Address ______________________________________________________

City ___________________________ State ____ Zip __________________

Province _____________ Country ______________ Postal Code _________

Work Phone (____) _______________

Agency or Company Name ________________________________________

Course Title ___________________________________________________

Course Starting Date ___/___/___

BILLING INFORMATION:
Agency/Company _______________________________________________

Address ______________________________________________________

City ___________________________ State ____ Zip __________________

Authorizing Signature _____________________________________________

please mail or fax to: 1190 Scottsville Road Rochester, New York 14624

585-753-3850 (fax)

Note: Classes with insufficient enrollment may be cancelled.