Page 11 - NATA

Registration Form (Page 1)
Registration

Northwestern Area Training Academy
EDUCATIONAL CONFERENCE
REGISTRATION DEADLINE:
November 1, 2017 November 4 & 5, 2017

Registration Fees: First Name: ________________________________________________________
• One Day = $50.00
Last Name: ________________________________________________________
• Two Day = $100.00
NOTE: Fee includes Lunch and T-Shirt Street Address: _____________________________________________________
__________________________________________________________________
T-Shirts:
City: ______________________________________________________________
In order to fulfill your t-shirt request, you
must be registered two weeks prior to the State: _____________ Zip: ____________________
conference. Any requests received after
October 30, 2017 will filled by availability Contact Phone: _____________________________________
of sizes.
Email: _____________________________________________________________
Volunteer Firefighter Training Fund
Credit: Birth Date (Mo/Day/Year): ________________________

Individuals from Iowa volunteer and com- SS#: _______ - ______ - ________
bination departments registered in the
following courses will receive a $15.00 Registration Fees & Credits:
reduction per day in ther fire school
registration, due to partial grant funding One Day Registration . . . . . . . . . . $50.00
from the Volunteer Firefighters Training Fund.
Two Day Registration . . . . . . . . . . $100.00
• Big Rig Rescue
• Vehicle Rescue Extrication Training Fund Credit:

Ways to Register: Big Rig Rescue . . . . . . . . . . . . . . - $15.00
• Register by Phone: Vehicle Rescue Extrication . . . . .- $15.00
1-800-362-2793, Ext. 1322 or
515-574-1322 TOTAL . . . . . . . . . . . . . . . . . . . . . . . . $ ___________

• FAX BOTH pages of the Method of Payment:
Registration Form to:
515-574-1321 Payment enclosed: $ ___________
Bill this Service /Organization: _______________________________________
• Mail BOTH pages of the
Registration Form to: ___________________________________________________________________
AST Building - Attn. Joan
Iowa Central Community College Attn: _______________________________________________________________
One Triton Circle Address (Street/City/State/Zip): __________________________________________
Fort Dodge, IA 50501
___________________________________________________________________

For security purposes please call or fax credit card information!
Refund/Cancellation Policy:
A full refund will be given for cancellations Credit Card: Visa MasterCard
prior to November 1, 2017. After that
date, there will be no refunds! This policy Exp.Date: _______________ CVC: ___________
will be strictly adhered to. NATA reserves Cardholder Name: ____________________________________________________
the right to cancel any session that
does not meet the minimum registration Card Number: ________ - _________ - ________ - ________
requirement or to change the instructor.
Cardholder Address (Street/City/State/Zip): _________________________________
___________________________________________________________________