Fall 2017 Chemical Grouting Institute Enrollment Form

Name (Attendee 1)*

First NameLast Name

Company*

Email for attendee 1:*

Additional Attendees Full Names:

Email for attendee 2:

Email for attendee 3:

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

We will provide lunch on both days. Please let us know if attendees have dietary restrictions so that we may accommodate them.

If the best contact differs from the name(s) of the attendee(s), please leave your information here:

Are you a current Prime Resins or Aries customer?

YESNO

My Products*

Single Attendee $500.00

Additional Attendee from same company$400.00

Quantity

Enter coupon

Total $0.00

There is a $75.00 cancellation fee for all registrations cancelled within five business days of the training.

NO DAY-OF, ON-SITE (WALK UP) REGISTRATIONS.

May 2020