REGISTRATION FORM

FREE* Basic 30-Hour Accident Prevention Certificate Awareness Program
Presented by N.C. Industrial Commission Safety Education Section
June 15-19, 2009
at the
 Town of Smithfield
Town Hall
111 South 4th Street
Smithfield, NC 27577

*There will be a $4.00 per person charge, payable at the workshop,
to cover the defensive driving course book.

 

INSTRUCTIONS: Fill out and click the Send E-mail button below to send in the following form.  Your email server will open with a new email.  Click send within your email program to submit the registration.  
 

E-MAIL REGISTRATION FORM FOR APCAP COURSE

First Name:                                

Last Name:               
 

Position:                   
 

Company:                 
 

Address:                    
 

City:                                State:       ZIP: 

Phone:                  

E-mail Address:        
 

 Please check box to be added to e-mail list.

Note: The Comfort Inn is offering a rate of $63.75 per night, plus tax, for the Smithfield APCAP. Please make hotel reservations directly with the Comfort Inn, 170 S. Equity Drive, Smithfield, NC 27577; (919) 938-4444. When making reservations, please mention NCIC, which is the Promotion Code for special room rates!

N.C. Industrial Commission ·   Safety Education Section
4339 Mail Service Center ·   Raleigh, NC 27699-4339
Telephone: (919) 807-2603 ·   Fax: (919) 715-6573
NCIC Home Page: http://www.ic.nc.gov//