ServSafe Food Safety Manager Certification Class

Registration Form

Today’s Date: _____________________

Course Date: Thursday, August 28, 2008

Course Location: Atrium of Carmichael, 5757 Cypress Ave., Carmichael, CA 95608

Time: Registration – 7:00am – 7:45am Class – 8:00am – 4:00pm Lunch – 12:00pm – 1:00pm

U.S Foodservice Customer ID# _________________________(required for discount) $99.00

Fee Enclosed: $ _______________ (Non U.S Foodservice Customers $180.00 per person)

TO RECEIVE YOUR STUDY MATERIALS

Name: ___________________________________________________

Company: _______________________________________ Title: ____________________________

Address: (no P.O. Boxes please)___________________________________________________

City: ___________________________________ State: ___________________ Zip: ____________

Daytime Phone: _________________ Fax: ________________ Email: ____________________

Payment Method: Payment must be included with your registration and is payable by check only.

Make checks payable to Hospitality Consultants of America and mail to

716 Lighthouse Avenue – Suite G, Pacific Grove, CA 93950

English _________ Spanish _________

Fax completed form to 1-831-375-1707 or mail to Mr. Abraham Wilson,

716 Lighthouse Avenue – Suite G, Pacific Grove, CA 93950

Telephone: 1-800-953-3822 for inquiries