Class Enrollment Form

Course cost is $25.00 per person

Start Date of Class (MM/DD/YY):    City: ======Select the City======= Addison, Texas Ft. Worth, Texas

    Company Name (If Applicable):

                                    Last name:      First Name:       MI:

                                       Address:      Apartment:  

                                            City:               State:                Zip Code: 

                                 Phone: (Day): (Night):

Note: If this is for a company doing a group enrollment, please enter the number of students this enrollment is for:
and list their names in the Questions/Comments/Additional Student Names box below.

   Your Email Address:

You may bring cash check, or credit card make checks  payable to: "Paragon Safety Institute" the first day of class or call 972 223-0007 and ask for billing
 

How did you hear about us?

T.A.B.C.      Friend        Employer        Business Associate         College          Other

Questions/Comments/Additional Student Names