Section A Client/Agency Information

  Student/Client

  (Last, Name, First, MI)

Date  

SS# (last 4 digits)  

Title  

  Organization:

Telephone:  

  Address:

  (City, State, Zip)

Fax:  

  Country:

E Mail:  

Section B Course Information

   Course Title:

Section C Method of Payment

Contract

Order No.

Account No.

Authorization No.

Purchase Orders, Open Accounts, and Contract Purchasing will be invoiced based on pre-approval agreement. All others can mail payments to;

Canine Specialty Services

Institute of Management and Training

P.O. Box 124 Mountain Road

Monkton, Vermont 05469