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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. <br /><br /> 4 pesticide credits available! <br /> WHEN: 8:00 AM - 12:00 PM, March 3rd, 2020<br /> WHERE: Cowlitz County Event Center, 1900 7th Avenue, Longview, WA 98632<br /> REGISTRATION: $25 per individual<br /> <a href="http://www.co.cowlitz.wa.us/2650/Herbicide-Education">Return to Class Information Page </a>

   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.

    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