Registration Form for CEU Hours

Name:__________________________________

Address_________________________________

City____________________________________

State____________________________________

Zip_____________________________________

Phone # (        ) ___________________________
E-Mail (optional)__________________________  

Enter Your Arizona License Numbers Below.
Private Applicator #________________________
Commercial Applicator #____________________
Pest Control Advisor #______________________


Signature___________________________________________Date__________________
For more information or assistance call:
Tim Braun: Home (928) 726-8958 Robert Braun (928) 580-7801
Email tbraun783@aol.com
(  )   Small Grain Weed Control
(  )   Cotton Weed Control
(  )   Corn Weed Control
(  )   Melon Weed Control
(  )  Lettuce Weed Control
(  )  Cole Crop Weed Control