CNG State Certification Registration Form

STUDENTS:

First Name:
Last Name:
Birthdate:	(mm/dd/yyyy)
Address:
City:
State:
Zip:
Day Phone:
Home Phone:
Email:
Class:
	Certification ($450.00)
Class Dates:
Please indicate which documentation of met prerequisite you are providing. Prerequisite documentation: (You only need to choose one of the following)
	ASE Certification (electrical and engine performance) 1 year work experience Automotive classes (electrical and engine performance) Not taking class for certification - Personal Interest Only
Note: No certification will be issued until proof of the above prequisites are met.
Credit Card Number:
Card Holder Name:	(As it appears on the card)
Billing Address:	(If different than above)
City:
State:
Zip:
3-digit security #:
Expiration Date:

To withdrawal from a class, the student must contact Kristi Fields at 682-7894. A full refund will be given for withdrawal prior to the start of class. If you are registered but do not cancel and do not attend, no refund will be issued.

I HAVE READ AND UNDERSTAND THE REFUND POLICY AND MY RESPONSIBLILITES REGARDING THIS ENROLLMENT.

Cardholder Signature:

__________________________________________________________________

Please PRINT the registration form then submit by MAIL with payment information. You should send a check, money order, P.O. or completed credit card information on the form. You may also fax this form to (405) 682-7549 or email to kfields@occc.edu.