* Email Address

* Company Address

*  City

*  State

*  Zip Code

* Your Phone

* Business Phone (include area code)  ext.

* Business Fax

* Conference/Seminar & Registration Amount Select Conference/Seminar You Wish to Attend........ Governor's Safety Summit, Nov. 1&2, 2001- $75.00 KY Aviation Maintenance & Operations Seminar-Booth Rental, March 20-21, 2002, $350.00 SPT New Personnel, Hinkle Contracting-$700 SPT New Personnel, Scotty's Tech Center- $700 Superpave Mix Design Technologist, Frankfort- $700 National Conference on Transportation and Historic Preservation, Lexington- $250 January 8, 2002- Pesticide Continued Training January 15, 2002- Pesticide Continued Training January 29, 2002- Pesticide Continued Training January 30, 2002- Pesticide Continued Training February 6, 2002- Pesticide Continued Training February 12, 2002- Pesticide Continued Training February 13, 2002- Pesticide Continued Training February 19, 2002- Pesticide Continued Training February 20, 2002- Pesticide Continued Training February 21, 2002- Pesticide Continued Training February 26, 2002- Pesticide Continued Training February 27, 2002- Pesticide Continued Training February 28, 2002- Pesticide Continued Training March 12, 2002- Pesticide Training & Testing March 14, 2002- Pesticide Training & Testing March 18, 2002- Pesticide Training & Testing

*Payment Information 

Please have a KTC staff member call me for Credit Card information (MasterCard or Visa only)
     *Person and Number to call: 
Mailing Check ( Please make checks payable to: University of Kentucky)

Paying with Purchase Order - *Purchase Order Number

Please note that registration for chosen course will not be confirmed until payment has been made.