Submit Online Please complete a registration form for each student and hit the "submit" button. If paying by credit card (Discover, MasterCard, Visa, American Express) call Steve (585) 216 - 2223 after submitting form. Please note that certificates will be issued 6 - 8 weeks after Course Completion. Please plan accordingly. Please supply a good email address below for business and student. You will be receiving emails with important class information and reminders. Company Business Phone Company Address City State Zip Business Email Student Name Phone Home Address City State Zip County of Residence Email NYS Cert# (if recertifying) Expiration Date CCCF Course Testing Dates - Check only One (one is required - either Initial or Recertification) Initial Class $750: Dec 11 - 14 Now FullMarch 4 - 7June 10 - 13Sept 9 - 12Oct 21 -24Dec 9 -12 Recertification $275: Dec 8 Now FullMarch 1March 8June 7June 14Sept 6Sept 13Oct 18Oct 25Dec 06 Payment Type: Credit CardCheckPO Payable to: Cross Connection Control Foundation with the amount $ Number of registrations If paying by credit card (Discover, MasterCard, Visa, American Express) call Steve (585) 216 - 2223 after submitting this form. You will receive a receipt/confirmation via email to the company email provided above. Mail Checks or POs to: CROSS CONNECTION CONTROL FOUNDATION, 255 Basket Rd. webster, NY 14580 Proper Id required before entry to class. Δ
