ETC COURSE APPLICATION FORM

Please complete this form at least six weeks prior to the start of the course.

Course Information

ETC Edition *

Course Type *

Advertise on PDC Website *

Start Date (mm/dd/yyyy) *

Month

Day

Year

End Date (mm/dd/yyyy) *

Month

Day

Year

Start Time *

End Time *

Instructors Name *

Instructors E-mail Address *

Host Agency

Host Agency Name *

Host Agency ID

Host Agency Contact *

Host Agency Address *

City *

State/Province *

Zip Code *

Telephone *

E-mail Address *

Course Location same as Host Agency *

Enter New Course Location

Contact Person *

Course Location *

Course Address *

City *

State/Province *

Zip Code *

Country *

Telephone *

E-mail Address *

Ship Course Manual to

Ship Course Manuals to *

Qty of Manuals Needed

Enter Quantity

Ship Course Manuals to this location

Qty of Manuals Needed

Enter Quantity

Agency Contact *

Shipping Address *

City *

State/Province *

Zip Code *

Country *

Method of Payment

Payment Method *

P.O. #

Billing Address same as Host Agency *

Enter new Billing Agency Address

Billing Agency *

Attn *

Billing Address *

City *

State/Province *

Zip Code *

Open Courses: Please provide the following information for this open course and the published price

Name

Phone

Price (USD)

Course application review and approval terms *

Yes, I understand that my course application will not be scheduled until it's been reviewed and approved by a Priority Dispatch representative. I will be contacted by a representative within two full business days.

Universal Course Agreement, Terms and Conditions
Universal Q Agreement, Terms and Conditions

Agree to Terms and Conditions *

Yes

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ETC COURSE APPLICATION FORM

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