MAIL-IN TRAINING REGISTRATION FORM

To register for ERC trainings please print this form and 
list which trainings you would like to attend.  Review, 
make a copy, and mail original form with your payment to:

ERC Resource & Referral
Attn: Resource Specialist
1710 SW 10th St., Suite 215
Topeka, KS 66604

Questions? Call 785-357-5171 or 1-800-279-2372 (long distance only)

Name: ______________________________________________________________

Center/Business: ______________________________________________________

Address:  ____________________________________________________________

Phone:  _____________________________________________________________

                    DATE                              COURSE TITLE                            COST

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