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PCH/CLA TRAINING REGISTRATION FORM NOTE Use one form for each DATE of training. NAME OF TRAINING SESSION Please note that the New Provider s Training fills up quickly. If the class listed above is filled and you would like to be scheduled for the next available class please indicate below Yes schedule me for the next available class. No do not schedule me for the next available class. Please schedule me for the class on the following date FROM Organization Address - Tel* No* Fax No* E-mail Address Print below the names and titles of individuals attending the training on the above date as you wish it to appear on certificates Name Title. If the class listed above is filled and you would like to be scheduled for the next available class please indicate below Yes schedule me for the next available class. No do not schedule me for the next available class. Please schedule me for the class on the following date FROM Organization Address - Tel* No* Fax No* E-mail Address Print below the names and titles of individuals attending the training on the above date as you wish it to appear on certificates Name Title.

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