Dick's Code Class Registration Form

Name*

First NameMiddle NameLast Name

MA Masters #

MA Journeyman's #

NH Masters #

NH Journeyman's #

VT Masters #

VT Journeyman's #

ME Masters #

ME Journeyman's #

RI Masters #

RI Journeyman's #

Generation i.e. Jr, 2nd, 3rd , etc

Street Address *

City *

State *

Zip Code *

Phone Number*

Work Phone Number

Company Name

City

State

Email Address *

CHOOSE FROM ONE OF THE FOLLOWING OPTIONS PART 1 🛈*

Additional 3.2% fee for credit card or Paypal

CHOOSE FROM ONE OF THE FOLLOWING OPTIONS PART 2 🛈*

Any questions?

Initialing the form indicates you will attend class and pay the associated fee.*

Return to www.dickscodeclass.com Registration & Payment page to submit payment via PayPal or Credit card.

Cost of the class is as follows:

21 hrs $315.00, Retirees $280.00

15 hrs $225.00, Retirees $200.00

6 hrs $105.00, Retirees $90.00

( CREDIT CARD ADD 3.2 % )