Please provide the information requested below and print the completed form for your records.
LAST/FAMILY NAME
FIRST/GIVEN NAME
MIDDLE NAME
E-mail Address:
Daytime Phone:
Local Address:
CITY:
STATE:
ZIP:
COUNTRY:
Company/Organization Name:
Select Course:
June 9-10 HACCP course - Pharmaceutical Risk Management Training Using HACCP Principles
September HACCP course - Medical Product Risk Management Training Using HACCP Principles
November HACCP Course - Pharmaceutical Risk Management Training Using HACCP Principles
Course Date:
Course Location:
Irvine, CA
Fee Details (Please check the fee applicable for your registration):
$850/Individual - Individual Registrations
$425/Individual - For the third and additional participants from the same company
$425/Individual - Government Employees
Select Method of Payment (Follow instructions below the options):
Payment by Check
Payment by Credit Card
Payment by Check:
Please make checks payable to:
Treasurer, Virginia Tech
Mailing Address:
Medical HACCP Alliance
ATTN: Laura S. Douglas
P.O. Box 11736
Blacksburg, VA 24062
Payment By Credit Card:
Only
VISA
,
Mastercard
and
Discovery
cards accepted. Call Laura Douglas at (540)231-6325 to provide your credit card information and confirm your registration.
Questions? Call (540)231-6325 or email
medicalhaccpalliance@yahoo.com