Ncecc-Iaei, Ncdoi-Osfm, Ncaec Continuing Ed Courses

NCECC-IAEI & NCDOI-OSFM, CONTINUING EDUCATION COURSES REGISTRATION FOR ONE DAY WORKSHOPS

NAME (Last, First, Middle)______

COMPANY/JURISDICTION ______MAILING ADDRESS______

CITY______STATE____ZIP CODE______PHONE #______

EMAIL ADDRESS______IAEI MEMBERSHIP #______

COURSE SELECTED AND FEES:

[ ] April 27, 2017 – Blue Water Banquets & Catering, Wrightsville Beach, NC (Meal Included) $_____ [ ] Member – $60 [ ] Non Member $105 [ ] Join IAEI $145 – Must complete membership application and submit with registration

[ ] May 11, 2017 – PWC Operations Complex, 955 Old Wilmington Road, Fayetteville, NC $ _____ [ ] Member – $45 [ ] Non Member $90 [ ] Join IAEI $130 – Must complete membership application and submit with registration

[ ] May 18, 2017 – Macon County Community Facilities Building, Franklin, NC $ _____ [ ] Member – $45 [ ] Non Member $90 [ ] Join IAEI $130 – Must complete membership application and submit with registration

Quantity [ ] 2017 Analysis of Changes Book $75.00 $______[ ] 2017 National Electrical Code Book $110.00 $ ______

Total $ ______

ADDITIONAL INFORMATION REQUIRED FOR CONTINUING EDUCATION CREDITS: NC Board of Examiners of Electrical Contractors – Last 4 digits of s.s. # ______NC Code Officials Qualification Board – Inspector ID # ______(do not use certificate #)

MAKE CHECKS PAYABLE TO NC ELLIS CANNADY CHAPTER AND RETURN TO:

NC Ellis Cannady Chapter, IAEI, Attention: ReBecca Latham, NC Department of Insurance, Office of State Fire Marshal, 1202 Mail Service Center, Raleigh, NC 27699-1202

Attention: ReBecca Latham. If using a credit card for payment, you may fax to ReBecca Latham at (919) 715-0063 Questions, call ReBecca Latham at (919) 647-0013 or [email protected] .

Visa or MasterCard Accepted [ ] Visa [ ] MasterCard

Name on Card______Card # ______

Expiration Date MM/YY______Signature______

Billing Address______Billing Zip Code______

√ Registration is from 7:30 to 8:00 AM, Class ends at 5:00 PM √ Additional books will be available at the workshop (Limited books available at workshops for a fee) √ For more information visit: www.nciaei.org. √ Funds collected for registration are non-refundable. If course is cancelled by NCIAEI student may attend another course offered by NCIAEI or request a refund.