Registration Form

2012 Dot Substance Abuse Professional 2 Day Qualification / Requalification Training 
&
The IC&RC DOT/SAP Written Examination

 (Please circle the date & location of choice.)

Dates

City / State

Training Site

2012 Schedule
March 14, 15, 16 Atlanta, Georgia TBD
April 11, 12, 13 Detroit, Michigan Walsh College, Troy
May 9, 10, 11 Cleveland, Ohio CID Lakewood
June 20, 21, 22 St. Louis, Mo. Airport Holiday Inn
July 11, 12, 13 Columbus, Ohio Comfort Inn, Polaris, Ohio
August 8, 9, 10 Washington, D.C. Holiday Inn West Laurel, MD
September 10, 11. 12 New England Institute for Addiction Studies Waterville Valley Resort
September 26, 27, 28 Cleveland, Ohio CID Lakewood
October 17, 18, 19 Detroit, Michigan Walsh College, Troy
December 5, 6, 7 Las Vegas, Nevada Sam's Town

Note: The two day training can be used as a refresher course for the individual who is already a qualified SAP as it meets the DOT/SAP re-qualification criteria for 12 contact hours.   

Training Registration Fee: $295.00. Registration:  8:30 a.m.; Training 9:00 a.m. - 4:00 p.m.
Training includes: 
 
           Training Manual and Study Guide for IC&RC DOT/SAP Qualification Test
    
          Continental Breakfast and Refreshments each day
    
          12 CEU’s Approved Education Credit: EAP's, Counselors & Social Workers
Test Registration Fee: $125.00 · Test Dates in Bold

              Registration: 8:30 a.m.; Testing: 9:00 a.m. - 11:00 a.m. (2 hour limit) 

Name: _______________________________________________Phone #:________________
Agency: ______________________________________________________________________
Address: _________________________________________ Email:______________________
City: ______________________________________ State: _________ Zip:________________
Training Fee: $295.00 ____ Testing Fee: $125.00 _____Total Amount Enclosed: ________
 ______________________________________________  / ________________   ____________

Visa/MasterCard Number                                                       Expiration Date      3 digit code
Signature: ____________________________________________________________________
Enclose the registration form with check or Visa/MasterCard number payable to:

Professional Training Center, Inc.
P.O. Box 295 · Marysville, Michigan  48040
Phone: (810) 388-0200      Fax: (810) 388-1342
email Tom Foley: tfa@tir.com

Confirmation Letters with specific location and directions will be sent upon receipt of registration.