<p> NCECC-IAEI & NCDOI-OSFM, CONTINUING EDUCATION COURSES REGISTRATION FOR ONE DAY WORKSHOPS</p><p>NAME (Last, First, Middle)______</p><p>COMPANY/JURISDICTION ______MAILING ADDRESS______</p><p>CITY______STATE____ZIP CODE______PHONE #______</p><p>EMAIL ADDRESS______IAEI MEMBERSHIP #______</p><p>COURSE SELECTED AND FEES:</p><p>[ ] 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 </p><p>[ ] 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 </p><p>[ ] 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 </p><p>Quantity [ ] 2017 Analysis of Changes Book $75.00 $______[ ] 2017 National Electrical Code Book $110.00 $ ______</p><p>Total $ ______</p><p>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 #)</p><p>MAKE CHECKS PAYABLE TO NC ELLIS CANNADY CHAPTER AND RETURN TO:</p><p>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</p><p>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] .</p><p>Visa or MasterCard Accepted [ ] Visa [ ] MasterCard</p><p>Name on Card______Card # ______</p><p>Expiration Date MM/YY______Signature______</p><p>Billing Address______Billing Zip Code______</p><p>√ 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.</p>