Nebraska Rural Water Association Wastewater License Preparation Class Online Registration Form

Fields Marked with an Asterisk (*) are Required

*Name:

*Employer (Self if None):

*Business Mailing Address:

*Business City:

*State:

*Zip Code:

Business Telephone:

Email:

*Home Mailing Address:

*Home City:

*State:

*Zip Code:

Home Telephone:

*Will You Need Required Class Books? ($98.00 per set)

Yes

No

Do You Want Your Books Shipped? ($12.00 shipping)

Yes

No

Books Should be Shipped to:

Business

Home

*Class Attending:

Choose Session You Will be Attending ---------June 11 - 14, 2013, Wahoo ($200.00) ---------August 27 - 30, 2013, Wahoo ($200.00) ---------September 24 - 27, 2013, Wahoo ($200.00)

Please provide any questions, remarks or comments in the space provided to the right.