CoDeSys Programming Registration

Name: (First, M.I., Last)      
Date of Birth: January February March April May June July August September October Novemeber December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935
Home Address:
City/State/Zip: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware 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 Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Daytime Phone:  
Email Address:

Program Selection: Basic CoDeSys Programming $1200 CoDeSys Power Programming $1000 CoDSys Programming Series (both) $2000

Payment

(payment, purchase order, or billing information must accompany registration)*

Check (payable to Alexandria Technical College)
Mail check to:
Alexandria Technical College
1601 Jefferson Street
Alexandria, MN 56308

Purchase Order Number

Bill my Employer
Employer Name:
Address:
City/State/Zip: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware 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 Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Contact Name:
Phone Number:

Credit Card (VISA/MasterCard/Discover) Please contact the Customized Training Center at the Alexandria Technical College to
give credit card information at 320-762-4510 or 1-888-234-1313.