NERIC REGISTRATION FORM
1. Send form by FAX (518 456-9287) or mail to: Capital Region BOCES NERIC,
1031 Watervliet-Shaker Rd, Albany NY 12205
Attn: Ann Shattuck
2. Forms must arrive one week prior to date of session. Use one form
per individual
3. "No shows" will be billed at the daily workshop rate.
No refunds.
4. A separate memo will confirm registrations.
5. NERIC Training Certificates (if applicable) are held by building
principal.
Name:___________________________ District:_______________________________ Bldg: ______________________ Work Address:_____________________________________ Work Phone:__________________ Fax:________________ Email Address:_____________________________________ Home Address:____________________________________ Home City, State, Zip:_______________________________________________ Home Phone:______________________
|
| Name of Session | Location | Fee (incl. Mat) |
Date/Time of Session |
| __________________________ | _____________________ | __________________ | ____________________ |
| __________________________ | _____________________ | __________________ | ____________________ |
| __________________________ | _____________________ | __________________ | ____________________ |
| __________________________ | _____________________ | __________________ | ____________________ |
Payment Options-(Check payment option below): |
FOR BOCES USE ONLY |
| [ ] NERIC Training Certificate # _______ (mail original) | 1. Confirmed _________ |
| [ ] Check enclosed (district check preferred) | 2. Bill # _________ |
| [ ] "I authorize NERIC to bill the School District named above for this training workshop." | 3. Payment _________ |
| Signed _________________________________ Title____________________________ | 4. Amount _________ |
|