Class Registration Form

ONLINE Courses

1st Quarter and 2nd Quarter, 2013

• You will receive confirmation of your registration via e-mail.
IMPORTANT: You must use the drop-down menus to fill in the registration form.

Submit this form ONCE for EACH employee being registered.

Name of Employee being registered:
Employee’s Telephone Number:
Employee’s Email Address:
Employee’s Date of Birth:
The employee is a Kentucky Resident.	YES NO
Course Title:
Course Starting Date:
Company Name:
Company Contact Telephone Number:
Company Contact Email Address:
Company Address:
Company City:
Company Zip Code:
Additional Comments (Optional):
By checking this box, I certify that the enrolled employee has given permission for his/her name to be viewed in class enrollment reports. No other personal information will be listed in enrollment reports. (NOTE: The form cannot be submitted unless this box is checked.)