Registration Form
Building Lean Culture
Specialty Certification Program

*** This is NOT a secure site. ***
If paying by credit card, you MUST print this form and fax it to us. Fax: 859.257.1071
 

Date
Dr., Ms., etc....
First * Required
Middle Initial
Last * Required
Preference for
Name tag
Job Title
Department
Company * Required
PO Box
Street Address * Required
City * Required
State * Required

Province

County
(if located in KY)
Zip Code * Required
Country
Business Phone    ext. * Required
   [ex. 555-555-5555]
Cell
Fax
Email * Required
Website Address
How did you hear about our program? * Required
  Word of Mouth
  Former Attendee
  Print Ad (magazine, journal, ect.)
  Email Ad (from the University of Kentucky)
  Internet (search, website, ect.)
  Brochure
Conference / Trade Show
  Other
If you have a special
need that may require
accommodation or assistance, please explain:

Building Lean Culture $2,495.00

Select date:
No dates at this time.

Payment is made by: 		 
Send invoice to my company    Send invoice to me
Payment/purchase order enclosed 
Purchase order No.



Please make check/purchase order payable to: University of Kentucky

Cancellations made less than 10 days before the course will be subject to the full fee.

*** This is NOT a secure site. ***
If paying by credit card, you MUST print this form and fax it to us. Fax: 859.257.1071

Circle One:

Visa  
MasterCard
American Express
Discover

Card Number_____________________ Expiration Date ______________

Security Code________ Billing Address Zipcode _____________
 
Cardholder
 Signature _____________________________________________________________

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For General Information and
 Public Course Registration Contact:
Sandra Dunn
Email:sdunn@engr.uky.edu
Phone: 859-257-6262, ext. 214
Toll Free: 800-227-6268
Cell: 859-338-3742

For Customized Solutions or
Dedicated Training Contact:
HeatherMichele Adkins
Email:hadkins@mfg.uky.edu
Phone: 859-257-6262, ext. 458
Toll Free: 800-227-6268
Cell:859-684-0311


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