Backflow School Registration Form

Company:     Business Phone:

Address:       City:

State:         Zip Code:       Business Email:

Student Name:      Phone:

Home Address:       City:

State:      Zip Code:    County of Residence:    Email:

*NYS Cert #      * Expiration Date       *Recertification students only

CCCF Course/Testing Dates

Check One: Initial Class  $595 ($615 w/credit card): Recertification $195 ($205 w/credit card):

Check one:     Credit Card         Check           PO  payable to :

Cross Connection Control Foundation  $ to cover  registrations.

If paying by credit card (Discover, MasterCard, Visa, American Express)  call Steve (585) 216 - 2223

Please note that certificates will be issued 6 - 8 weeks after Course Completion. Please plan accordingly.

Mail to:  CROSS CONNECTION CONTROL FOUNDATION 255 Basket Rd. Webster, NY 14580

Please print this form with your registration fee.  Travel and lodging information will be sent with a letter confirming your registration. Please supply a good email address above.

         (use the print button at the top left of form to display just the form for printing)