EPATC Training Registration Form
Please complete the responses below to register for your selected training course.
*By completing this form, you authorize LaSorsa & Associates to accept full payment of the course registration fee.
*Payment must be made in full in order to complete the registration unless a payment plan has been authorized.
*Once your payment and registration form are received and processed, you will receive a confirmation notice.
*No refunds once confirmed – you may request to attend another course at a later date within 12 months. If hotel package is selected and registration is confirmed, deferring to another course date may add additional costs/fees.
*Course content, instructors and outlines are subject to change.
*LaSorsa and Associates is not responsible for any travel costs or other expenditures which may be incurred in connection with training.
*By submitting this form, you are declaring that everything entered herein is true and accurate to the best of your knowledge and agree that LaSorsa and Associates may withhold any fees paid for this course if it is found that information submitted in this application is incorrect or false.
NOTICE: This document is confidential. Information contained herein is protected under state and federal law. Unauthorized use, review, duplication, disclosure, or retention of this information is prohibited. Please contact us with any questions. Copyright © 2020 LaSorsa and Associates, LLC. All rights reserved
* Required
Email address
*
Your email
Course Information
See our training schedule here:
https://www.lasorsa.com/training-schedule-registration/
Select Course:
*
Choose
4 Day EP $1,495
Course Location
*
I.E. Miami, FL
Your answer
Course Dates
*
I.E. 10/20-28/2018
Your answer
Registrant Information
Last Name
*
Your answer
First Name
*
Your answer
Phone (Mobile)
*
I.E. 123-123-1234
Your answer
Male or Female
*
Choose
Male
Female
Company Name
Your company's name or your employer
Your answer
Facebook URL
Your answer
LinkedIn URL
Your answer
The exact Name you want on your certificate
*
Your answer
Referred from?
*
Friend/Associate
Online Search
Facebook
LinkedIn
Magazine Ad
Other:
Required
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Payment Method
*
-PayPal, Credit Card, Debit Card: Complete this form and then use the link which will be provided. If by Check: submit this form and we will contact you for further instructions.
Choose
PayPal, Credit Card, Debit Card
Check
Training Agreement
I CERTIFY THE INFORMATION IN THIS FORM IS ACCURATE TO THE BEST OF MY KNOWLEDGE AND I AFFIRM MY WILLINGNESS TO CONSENT TO A NON-DISCLOSURE, NON-USE, ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT PRIOR TO ENGAGING IN ANY TRAINING.
SIGNATURE (Please type your full name)
*
Your answer
A copy of your responses will be emailed to the address you provided.
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