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
Email *
Course Information
See our training schedule here: https://www.lasorsa.com/training-schedule-registration/ 
Select Course: *
Course Location *
I.E. Miami, FL
Course Dates *
I.E. 10/20-28/2018
Registrant Information
Last Name *
First Name *
Phone (Mobile) *
I.E. 123-123-1234
Male or Female *
Company Name
Your company's name or your employer
Facebook URL
LinkedIn URL
The exact Name you want on your certificate *
Referred from? *
Required
Street Address *
City *
State *
Zip *
Payment Method *
-If by Credit Card, Debit Card or PayPal: Submit this form and you will be directed to https://www.lasorsa.com/training-payment/   -If by Check: make payable to LaSorsa and Associates 101 VFW Rd Ste 2E Cedar Point, NC, 28584   -If by ACH or Bank Wire: You will be sent the bank info via email
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.
Training Agreement: https://www.lasorsa.com/training-agreement/
SIGNATURE (Please type your full name) *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of LaSorsa & Associates. Report Abuse
Google Forms