Priority Dispatch - ETC Course Application Form

ETC COURSE APPLICATION

Please complete this form or download the PDF and email it to etcnumber@prioritydispatch.net or fax it to 801-363-9144 at least 30 DAYS before the course begins.

* Required Fields

ETC edition:*	[ ] 2nd Ed	[ ] 3rd Ed
Course Type:*	[] Open	[] Closed	Advertise on PDC Website:*	[] Yes	[] No

Start Date (mm/dd/yyyy):*			End Date (mm/dd/yyyy):*
Start Time (i.e. 8:00am):*			End Time (i.e. 5:00pm):*
Instructor Name:*

Host Agency Name:*			Agency ID:
Host Agency Contact:*			Phone:*
Host Agency Address:*
City:*	State:* Zip Code:*
Email for Course Confirmation:*

Course Location same as Host Agency:*	[] Yes	[] No
Course Location:
Course Address:
City:	State: Zip Code:

QTY of Manuals Needed:*	[ ] TBD (Open Courses: Must order at least 14 days prior to course)

Ship Course Manuals to:*	[] Host Agency Location [] Course [] Other

If Other, Agency Name:	Attn:
Shipping Address:
City:	State: Zip Code:

Method of Payment:*	[] Invoice [] P.0. #:
Billing Agency Name:*	Attn:
Billing Address:*
City:*	State:* Zip Code:*
* OPEN COURSES: PLEASE PROVIDE THE NAME AND PHONE NUMBER OF THE PERSON RESPONSIBLE FOR TAKING REGISTRATIONS FOR THIS COURSE AND THE PUBLISHED PRICE.
Name:	Phone: Price (USD):