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Pesticide Recertification Class Registration Form

2. Registration for March 3, 2020 Pesticide Recertification Class
   Please fill in the form below to register for the class. Participant information is required for each attendee in order to receive credit for the course. If payment information is different for each participant please fill out separate forms.
   
   4 pesticide credits available!
   WHEN: 8:00 AM - 12:00 PM, March 3rd, 2020
   WHERE: Cowlitz County Event Center, 1900 7th Avenue, Longview, WA 98632
   REGISTRATION: $25 per individual
   Return to Class Information Page
3. 
5. Participant Information
7. Number of Participants*
   -- Select One --12345
9. Participant 1: First Name*
10. Last Name*
11. Email*
12. Pesticide License #
14. Participant 2: First Name
15. Last Name
16. Email
17. Pesticide License #
19. Participant 3: First Name
20. Last Name
21. Email
22. Pesticide License #
24. Participant 4: First Name
25. Last Name
26. Email
27. Pesticide License #
29. Participant 5: First Name
30. Last Name
31. Email
32. Pesticide License #
34. If your agency or company has more than 5 individuals attending, please submit an additional form for those participants.
38. Billing Information
    Class registration fee is $25.00 per person, and should be submitted prior to the class. Please complete the billing information below, and submit payment to: Cowlitz County Noxious Weed Control Board, Admin Annex 1st Floor, 207 Fourth Ave N. Kelso, WA 98626. Checks may be submitted by mail or cash payments may be accepted at our office. An Invoice and/or receipt will be sent accordingly.
40. Agency / Company*
42. Billing Contact*
44. Billing Address 1*
46. Billing Address 2
48. City*
50. State*
51. Zip*
55. Person Submitting the Form
    If you are submitting this form and are not a participant above, please complete this contact information in case there are questions related to attendees or billing.
56. Email
57. Phone
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59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field