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SRT I Registration; Nantahala River; September 2020
Please complete this form to register for your upcoming Swiftwater Rescue Technician course.
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First Name
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Your answer
Last Name
*
Your answer
Email address
*
Your answer
Agency Type
*
Fire Dept.
Rescue Squad
EMS
Military / Special Ops.
Law
Outfitter
Agency Name
*
Your answer
Home Phone (No Spaces)
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Your answer
Cell Phone (Please No Spaces)
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Street Address
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Your answer
City
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Your answer
State
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NC
VA.
SC
GA.
FL.
TN.
Other (Please specify)
Zip Code
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Course Cost:
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Choose One
First Time Student $390
Re-Certifying Student $265
Payment Method
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What is your prefered method of payment?
Credit/Debt ( 3.7% +.40 processing fee for all Credit Card Payments)
Cash
Personal Check
Agency/ Business Check
Invoice (please provide Invoice information below)
Other:
Credit Card Information
Name As Appears On Card
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Credit Card Type
There is a 3.7% +.40 processing fee for all Credit Card Payments
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Visa
Master Card
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American Express
Credit Card Number
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Credit Card Security Number
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Address of Card Holder
Street Address; City, State, Zip Code
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Credit Card Expiration Date
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Card Holder's Phone Number
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Invoice to: Name; Address; City; State;Zip;
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