ENROLLMENT AND
BLACKLINE MASTERS INFORMATION FORM
Please complete this form. You may e-mail it to jimlucas@saber.net, fax it to 530-417-2474, or mail it to Jim Lucas, 2651 Crystal Springs Road, Camino, CA 95709.
Portions of the information you provide will be used to complete your blackline masters form. Fill in the information as you wish it to appear on your masters forms (e.g., Michael, Mike; James, Jim; Joseph, Joe, etc.) Choose your business name carefully. Compare it with other business names in your area’s phone directory.
Date ______________________
Name _______________________________________________________________________________
Mailing Address
______________________________________________________________________
City
_____________________________________________
State __________ Zip _______________
Business Name _______________________________________________________________________
Cell Phone _____________________________
Business Phone ________________________________
Fax ___________________________________ E-mail
_______________________________________
Voice Mail/Pager
____________________________ Home Phone
_____________________________
Home phone number to appear on your
master forms? Yes _____
No _____
Please indicate the courses you are interested in taking and the method of payment
_____ Home Study Course plus
Three-Day Classroom for Certification
_____ Manufactured Home
Inspector Training Course (one day for certification)
_____ Cashier’s Check (Preferred Payment Method) (Print and
sign enrollment
form and mail with check)
_____ Major Credit Card (Call
for credit card payments)
Fee for the Three-Day Training Course is $2995.00. Upon receipt of your payment the DVD home study material, training manual, reference books, and inspection report master will be sent to you. The fee for the Manufactured Home Course is $345.00. If you have questions, please call 530-417-2474 or e-mail me at jimlucas@saber.net.
I certify that the
information on this form is accurate and true.
I authorize Jim Lucas Enterprises, Inc., and Jim Lucas to investigate my
credit background to the extent deemed necessary or applicable.
______________________________________________
Signature