APPLICATION FOR THE NORTH CAROLINA INDUSTRIAL

VENTILATION CERTIFICATE PROGRAM

NAME_________________________________________________________________

TITLE_________________________________________________________________

DATE OF BIRTH________________________________________________________

COMPANY_____________________________________________________________

ADDRESS ______________________________________________________________

CITY _____________________________STATE_____________ZIP_______________

PHONE_____________________________FAX________________________________

E-MAIL_________________________________________________________________

WHEN WILL YOUR ENROLLMENT IN THE CERTIFICATE PROGRAM

BEGIN?_________ Which certificate? _____Industrial Ventilation Design

_____Monitoring & Maintenance

SUPERVISOR__________________________________________________________

ADDRESS (if different from above)__________________________________________

CITY________________________________STATE____________ZIP______________

PHONE______________________________FAX______________________________

E-MAIL_________________________________________________________________

AS THE SUPERVISOR OF_____________________, I APPROVE AND SUPPORT

HIS/HER PARTICIPATOIN IN THE INDUSTRIAL VENTILATION CERTIFICATE

PROGRAM SUPERVISOR’SIGNTURE________________________DATE_________

PARTICIPANT’S SIGNATURE_____________________________DATE_________________

APPLICATION FEE: $150 (THIS FEE IS NON-REFUNDABLE)

METHOD OF PAYMENT

CHECK_______VISA________MASTERCARD________AMEX________

CARD ACCOUNT NUMBER_____________________________________

EXPIRATION DATE________________AMOUNT___________________

CARD HOLDER NAME_________________________________________

CARD HOLDER SIGNATURE____________________________________

BILLING ADDRESS FOR CREDIT CARD:

One of the forms of payment must accompany your application form (if you did not pay when registering for the conference).

Mail to:

Industrial Ventilation Conference

PO Box 37129

Raleigh, NC 27627-7129

Attn: Connie McElroy-Bacon

Phone: 919.233.8400

Fax: 919.852-4594

E-mail: cbacon@mindspring.com

Website: www.ncindustrialventilation.com