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C-105 Roundtable Discussion Registration Form

 California Safety Certificate Program

Complete, copy and fax to:  AgSafe at 559-278-7035 or
Email as an attachment to safeinfo@agsafe.org   
Phone:  559-278-4404

 Make check payable to: AgSafe and mail to: AgSafe, P O Box 614, Clovis CA 93612

 C105:  $35 Certificate fee.
 Enter Name Here:

In order to be eligible to take C-105 Roundtable Discussion, you must have completed
courses 101, 102, 103, 104 and 4 elective hours. Any questions regarding eligibility, please call the AgSafe Office.

Check the class location that you would like to attend.
 
      DATE TIME LOCATION
Wednesday, April 19, 2006 1pm-5pm Fresno
        CAB Conference Room 2910 E. Barstow Ave. Fresno, CA 93740 (559) 278-4405
 
Monday, May 8, 2006 1pm-5pm Salinas
        Grower-Shipper Association, 512 Pajaro St, Salinas, CA 93901 (831) 422-8844

 

* * *Please note there is no fee for the roundtable discussion, only to have a printed certificate of completion of the California Safety Certificate Program.

Certificate fee: $35   $
(C105 Only) Total: $
 

NAME:

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or CELL:

ORGANIZATION:

 FAX:
STREET:
CITY:
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ZIP:

EMAIL:
 

****Registration needs to be completed 7 days in advance of the class, in order for us to ensure there will be enough participants for the classes to be held.*****

    

 

 

safeinfo@agsafe.org · Phone: (559) 278-4404 · Fax: (559) 278-7035