2012-2013 Private Pesticide Training and Certification Clinics

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Please make your registration selections below. If you would like to register multiple individuals with one payment, please complete the form below for each person. After each form, you will be prompted to add another individual or complete the registration process.

Fields marked with an asterisk * are required.

Contact Information of Attendee

Please enter the contact information for the person attending the training.

First Name*
Last Name*
Address*
Address 2
City*
State*
Zip Code*
County (IL only)
Phone 1* - Phone 1 (part 2) - Phone 1 (part 3) Ext. Phone 1 Extension
Phone Type Home Cell
Phone 2 - Phone 2 (part 2) - Phone 2 (part 3) Ext. Phone 2 Extension
Phone (Secondary) Type Home Cell
E-mail Address

Clinic Location and Date

Please choose the clinic location and date for the above registrant.

Clinic

The Mt. Vernon clinic on 11/28/2012 will be held at Holiday Inn, 222 Potomac Blvd. (I-57 & Rt 15)

The Utica clinic on 12/04/2012 will be held at Celebrations 150 Ltd., 740 E. US Highway 6 (Hwy 6 east of I-39)

The Carterville clinic on 12/11/2012 will be held at John A. Logan College Conference Center, 700 Logan College Road

The Champaign clinic on 12/14/2012 will be held at I-Hotel Illinois Conference Center, 1900 S. First

The Jacksonville clinic on 01/10/2013 will be held at Hamilton's, 110 North East Street

The Rockford clinic on 01/17/2013 will be held at Clock Tower, 7801 E. State Street (I-90 & Business 20)

The Rock Falls clinic on 01/18/2013 will be held at Rock Falls Hotel & Conference Center, 2105 First Avenue

The Bloomington clinic on 01/23/2013 will be held at Chateau Hotel and Conference Center, 1601 Jumer Drive

The Champaign clinic on 02/01/2013 will be held at I-Hotel Illinois Conference Center, 1900 S. First

The Effingham clinic on 02/07/2013 will be held at Convention Center at the Hilton Garden Inn, 1202 N. Keller Drive (I-57 & I-70)

The Galesburg clinic on 02/11/2013 will be held at Lake Storey Pavilion 1572 Machen Drive

The Kankakee clinic on 02/15/2013 will be held at Riverstone Confernce Center at the Hilton Garden Inn, 455 Riverstone Parkway

The Peoria clinic on 02/19/2013 will be held at Civic Center Room, 201 S.W. Jefferson Avenue

The Collinsville clinic on 02/28/2013 will be held at Gateway Center, 1 Gateway Drive (Rt. 157 & I-70)

The Dekalb clinic on 03/05/2013 will be held at University Plaza Conference Center, 900 Crane Drive

The Lincoln clinic on 03/11/2013 will be held at Knights of Columbus, 217 N. Limit Street

The Moline clinic on 03/21/2013 will be held at I-Wireless Center, 1201 River Drive

Related Publications

Please enter the number of each publication you would like to order.

Dealer Manual @ $15.00 each
Grain Facility Manual @ $15.00 each
Grain Facility & Seed Treatment Workbook @ $2.00 each
Private Applicator Workbook @ $2.00 each
Private Applicator Manual @ $10.00 each
Calculator @ $5.00 each

Ship these publications to a different address than listed above

Shipping Address for Publications

Please complete the following section.

First Name*
Last Name*
Company
Address*
Address 2
City*
State
Zip Code*

Cost of Training and Publications

Item	Cost
Registration Fee (training)	$0.00
Publications Cost (includes $1.50 per item shipping)	$0.00
Total Cost	$0.00

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