Name
: __________________________________________________________________________
(last) (first)
(middle)
Company/Organization : _____________________________ Title
: ______________________
Address : ________________________________________________________________________
__________________________________________________________________________________
Phone : __________________________________________________________________________
(daytime)
(evening)
E-mail
: ___________________________________________________
Please check the class you will prefer to attend.
September 24-25, 2003 (San Francisco)
How did you hear about us ? _______________________________________________________
Please write a check or money order for $1175 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: ____________________________________
For American Express give CID number_____________ (4 digit
# on top of card)
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_________________________________________