Emerson Educational Services - Enrollment Request Form

Registration Request: DeltaV^TM Courses
*Educational Services will contact you to COMPLETE* and CONFIRM your enrollment. Be prepared to provide a purchase order number or a valid credit card to process your request. Acceptable credit cards include: Visa, Mastercard and American Express. We value your business and the trust you have placed in Emerson. We take the protection of our customer’s information very seriously. Due to the inherent risks associated with the internet and as part of our ongoing commitment to our customers, we are informing our customer NOT to email their credit card information. There are many risks with sending personal information, especially through the internet. Please feel free to contact us at 800/338-8158 or 641/754-3771** to provide your credit card information or if you have any questions or concerns. Please complete the registration form fully and provide your country of citizenship. Note that classes do fill quickly, so please consider enrolling 6 to 8 weeks prior to the start date of the session you are interested in attending. We reserve the right to cancel or reschedule a school up to 14 calendar days prior to the start date. If you intend to order airline tickets with penalty clauses, please call to check the course status. * Indicates a required field to enroll DeltaV Courses * * Preferred Course Date Student Name: * First M * Last * Job Title Contact Information: * Phone * Cell * Email * Company Legal Entity Name * Country of Citizenship Your Account Payable Billing Address: * Address * City * State/Province * Postal Code * Country Your Site Shipping to Address: * Address * City * State/Province * Postal Code * Country Additional Comments: Contact Information Emerson Process Management Educational Services, Registration P.O. Box 190; 205 South Center Street Marshalltown, IA 50158-2823 Phone: 800-338-8158 or Phone: 641-754-3771 FAX: 641-754-3431 e-mail: education@emersonprocess.com

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