www.kenvictraining.org

Registration

Prospect students can register with us in person, by calling us, by mailing or by filling the following registration form. In Person: we are located at 137-28 Northern Blvd Flushing, NY 11354 By Phone: calling us at 718-321-3322 By Mailing: filling and submitting the following form, mail a check (payable to Kenvic Professional Training) to: Kenvic Professional Training 137-28 Northern Blvd 2nd Floor Flushing, NY 11354 For any question, please call 718-321-3322 or Email us at info@kenvictraining.com *Required

Student Information
* First Name:
* Last Name:
Middle Name :
* Cellphone # :
Home Phone# :
Fax # :
* Email:
* Address: Mailing Address
* City:
* State/Province:
* Country:
* ZIP/Postal Code:
* Emergency Contact: (Last Name, First Name)
* Emergency Contact Number: 000-111-2222
* Relationship with Emergency Contact: Friends, Wife, Husband)
Making a Payment
Note: for payment by check, please leave the following blank, go straight to the end and click "Submit". You may refer back to the beginning of the registration form for further instruction.
Credit Card Number:
Expiration Date:
Security Code:
Name on Credit Card:
Amount to Be Charged:
Address: if it is different from your mailling address
City:
State / Province:
Country:
Zip Code / Postal Code:
Agreement* I agree that Kenvic Professional Training charges the above amount to my Credit Card listed in the form. I don't agree that Kenvic Professional Training charges the above amount to my Credit Card listed in the form.

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