STEP 1 of 2: Registration Choices, Personal Information and Address

Fields marked with a red asterisk (*) are required.

Registration Choices
* Registration Type:
First time: Taking the examination for the first time - ($120.00)
Re-test: Taking the examination again - book not included - ($75.00)
Proctor: Proctor an Exam - ($75.00)
 
* Location of the Food Safety class you will attend:


Name and Address
* Salutation:   * First Name: * Last Name:  Suffix:
     
* Title:
  Organization:
* Address Line 1:
  Address Line 2:
* City: * State: * Zip:
 
 
* Phone: Ex: 123-456-7890 Fax: Ex: 123-456-7890
 
* E-mail Address:
* Please retype E-mail Address:

Additional Optional Information
  General Comments: