Contact Information
Name : __________________________________________________________________________________
(last) (first) (middle)
Company/Organization : _________________________________ Title : __________________________
Address : ________________________________________________________________________________
__________________________________________________________________________________________
Phone : _________________________________________________________________________________
(daytime) (mobile/evening)
E-mail : ___________________________________________________
Class Preference
Please check the class you will prefer to attend.
Currently not scheduled (San Jose)
How did you hear about us ? _________________________________________________________________
Registration Fee
Please write a check or money order for _____ (_____ if Linux laptop is included) payable to "LinuxCertified, Inc." (unless paying by credit card), and send it with this enrollment form to:
LinuxCertified, Inc.
1072 S. De Anza Blvd., Suite A107-19
San Jose, CA 95129
Payment by Credit card: Card number: ___________________________________
Expiration: ________________
Card type (circle one): Visa Mastercard American Express
Name on the Credit card: ________________________________________________
CID/CVV2 number:_____________(4 digit number on top of AMEX or 3 digit number at the end of signature panel of Visa/Master Card/Discover)
Signature: ___________________________________ Date: _____________________
Credit Card Billing address:_______________________________________________
_________________________________________________________________________
If paying by credit card, you can also fax the form to (425) 732-7143
Please do notify us via email when sending the form.
I have read and I agree to the Terms and Conditions listed on website of linuxcertified.com
Signature_________________________________________
