Plasker & Associates
Training Request Form
(Please print form, fill in information, and FAX to: (425) 827-2173)
ATTN: Valerie McNulty


Company Name:_______________________________________________________________________________________

Address: ____________________________________________________________________________________________

City: ___________________________________________________  State: WA               Zip:_________________________

Contact Person:_______________________________________________________________________________________

Phone: ________________________    Fax: ______________________   EMAIL: __________________________________

Please call Valerie McNulty at 425-827-8711 or cell 425-531-2246 if you need additional information or would like to receive a quote to schedule a class on-site or at our location.  Ask about group rates.

Student Name:   First ____________________________    Last _____________________________________                     

Over 18?   Yes  Class:     FIRST AID/CPR REFRESHER   [  ]               POWDER ACTUATED TOOL OPERATOR   [  ]
                                             
Class Date: __________________________    Cost: $_____________________  PO#____________________

Student Name:   First ____________________________    Last _____________________________________                     

Over 18?   Yes  Class:     FIRST AID/CPR REFRESHER   [  ]               POWDER ACTUATED TOOL OPERATOR   [  ]
                                             
Class Date: __________________________    Cost: $_____________________  PO#____________________


Student Name:   First ____________________________    Last _____________________________________                     

Over 18?   Yes  Class:     FIRST AID/CPR REFRESHER   [  ]               POWDER ACTUATED TOOL OPERATOR   [  ]
                                             
Class Date: __________________________    Cost: $_____________________  PO#____________________

Student Name:   First ____________________________    Last _____________________________________                     

Over 18?   Yes  Class:     FIRST AID/CPR REFRESHER   [  ]               POWDER ACTUATED TOOL OPERATOR   [  ]
                                             
Class Date: __________________________    Cost: $_____________________  PO#____________________

Student Name:   First ____________________________    Last _____________________________________                     

Over 18?   Yes  Class:     FIRST AID/CPR REFRESHER   [  ]               POWDER ACTUATED TOOL OPERATOR   [  ]
                                             
Class Date: __________________________    Cost: $_____________________  PO#____________________

Student Name:   First ____________________________    Last _____________________________________                     

Over 18?   Yes  Class:     FIRST AID/CPR REFRESHER   [  ]               POWDER ACTUATED TOOL OPERATOR   [  ]
                                             
Class Date: __________________________    Cost: $_____________________  PO#____________________
Fax completed form to:  Plasker & Associates, Attn: Valerie.   Fax number (425) 827-2173

POWDER ACTUATED TOOL Operator Safety Tranining: Approximately 30 minutes long - can be added to the FIRST AID/CPR Refresher Class
for an additional $25 per person. Fees will be waived with purchase of loads, pins or tools.
  CALL OR SEE US FOR ALL YOUR SAFETY NEEDS.
IF WE DON'T HAVE IT STOCK, WE CAN ORDER IT.
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