University of Illinois Extension
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Pesticide Safety Education Program

Preregistration Form

Preregistration Instructions

Company Name: ______________________________________
Address: ______________________________________
City: ______________________________________
State: ______________________________________
Zip: ______________________________________
Phone: ______________________________________

Please list clinic dates and individuals coming from your company. Use the codes in the box to indicate in column three which type of training you will attend at each clinic.

    Date        Attendee Name                   Training*

__________________________________________________________



 1. _____  __________________________________  ___________



 2. _____  __________________________________  ___________



 3. _____  __________________________________  ___________



 4. _____  __________________________________  ___________



 5. _____  __________________________________  ___________



 6. _____  __________________________________  ___________



 7. _____  __________________________________  ___________



 8. _____  __________________________________  ___________



 9. _____  __________________________________  ___________



10. _____  __________________________________  ___________



              # attendees X $40 per clinic = $ ___________
*Category Codes
AQ - Aquatics MOS - Mosquito SP - Spanish General Standards
D&R - Demonstration and Research O - Ornamental T - Turf
FC - Field Crops PM - Plant Management TO - Test Only
GF - Grain Facility ROW - Right-of-Way VEG - Vegetable
GS - General Standards S - Seed Treatment