All classes will be held at the University of Arkansas Engineering Research Center in Fayetteville, AR. Class size is limited to 20 students. Tuition is $525.00 per class per attendee. *Please note that this is an increased fee for the 2006 training year.

Name: _________________________________________ SSN: ____________________

Title: ____________________________________________________________________

Company Name: ___________________________________________________________

Street/Mailing Address: ______________________________________________________

City: ______________________________ State: _______________ Zip Code: _________

Telephone: ____________________ Fax: ___________________ Email: _______________

Company Contact Person: ____________________________________________________
Course(s) Requested (See Course Schedule)

1._________________________________________________________

2._________________________________________________________

3._________________________________________________________
Please indicate if this is your first time to attend the class or if this is a re-certification.

First Time____ Re-Certification____ CTTP#_______
PROOF OF COMPLETION OF ATTENDANCE AT A RADIATION SAFETY COURSE MUST ACCOMPANY APPLICATIONS FOR THE SOILS AND ASPHALT CLASSES!!