Please print out the following registration form and fax or mail to: Pesticide Industry Council,c/o Landscape Ontario 7856 Fifth Line South, R.R. #4, Milton, Ontario, L9T 2X8 Tel: (905) 875-1805 Toll Free: 1-800-265-5656 Fax: (905) 875-3942 E-mail: pic@ptppic.com
Name: ___________________________________________________________________ Company: ___________________________________________________________________ Title: ___________________________________________________________________ Address: ___________________________________________________________________ City: ___________________________________________________________________ Postal Code: _____________________ Phone: ___________________ ext. ______ Fax: ________________________ E-mail: _______________________________ Licenced Exterminators Number: ______________________________________________ No. of Years in Pesticide Management: _____________________________________ Trade Association Membership: ______________________________________________ Private Trainer Public Trainer (if applicable)
Examiner Kit + Seminar ............................. $80.00 + G.S.T. + Shipping Payment Details Visa MasterCard Card Number: _____________________________________________________________ Name of Cardholder: ______________________________________________________ Expiry Date: ______________________ Signature: _______________________________________________________________