Course Name Select Your Class Contractor/Supervisor Initial Contractor/Supervisor Refresher Worker Initial Worker Refresher Inspector Initial Inspector Refresher Air Monitoring Tech Initial Air Monitoring Tech Refresher Management Planner Initial Management Planner Refresher Project Designer Refresher

Course Location Select Location Houston, Texas Corpus Christi, Texas Borger, Texas Other Course Date

Student Name:

Social Security No: Drivers License No (For LDEQ):

A PREVIOUS COURSE CERTIFICATE MUST be provided for all refresher courses unless taken from Envirotest, Ltd.

Previous course taken with Envirotest. Date:

Previous course was NOT taken with Envirotest, Ltd. Please submit previous certificate with Registration Form.

Use the Attach Certificate option below to sumbit a digital copy of your previous certificate with this online registration form -
or you can fax a copy to 713-782-3428, attn: Training Dept.

Attach Certificate:

Company Name: Contact Person:

Mailing Address:

City: State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Telephone: Fax:

E-mail address: (a confirmation will be sent to this email address)

Company/Personal Check: Purchase Order #: Credit Card*:

*If paying by credit card, please call 713-782-4411 and ask for Accounting Department to make payment.

• Advanced Registration and Payment are Required! Certificates will not be issued until payment is received. Se require registro y pago por adelantado. Los certificados no seran procesados hasta haber recibido su pago.
• Students registering for a Refresher course MUST send previous certificate to complete enrollment. (Required by TDH/LDEQ). Los estudiantes registrandose para un curso de repaso deben enviar su certificado previo para que su proceso de matricula sea completado.
• Envirotest, Ltd. reserves the right to cancel classes due to lack of participation. Students will be called and informed of the cancellation of a class. All cancelled course fees will be refunded. Envirotest, Ltd. se reserva el derecho de cancelar clases debido a ausencias. Dichos estudiates seran contactados e informados acerca de la cancelacion de la clase. Todos los pagos efectuados seran reembolsados.

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