Fort Worth Electric

812 E. 9th Street

Fort Worth, TX  76102

Phone (817)870-2266  Fax (817)870-2268

CONTINUED EDUCATION ENROLLMENT FORM

Date:          _______________________________                                            Provider:              # 1085

Name:        _______________________________________________   Course Number:  ________________

Address:     ______________________________________________________________________________

City:           ____________________________________________    State:  TX        Zip:  _________________

Home Phone:  _________________________________     Work Phone:  ______________________________

Mobile Phone:  ________________________________

TX License:    (Please Circle)        MASTER         JOURNEYMAN          License Number:  ________________

Course Date:   _______________________________                Classroom Location:  812 E. 9th Street

                                                                                                                                     Ft. Worth, TX 76102

Course Time:   _______________________________

Continuing Education Credit Earned for this Course:  4 Hours

Course Cost per Registrant:   $ 50.00

PAYMENT METHOD

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Type of Card:    (Please Circle)         MASTERCARD         VISA

               Expiration Date (month and year):  ____________________________________________________

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Signature:   ________________________________________________     Date:   _____________________

          By signature, I agree with the terms and conditions of the refund policy attached.

FOR OFFICE USE ONLY

Payment Status:   _________________________________     Received By:   __________________________