ICC Enrollment Form

ICC Indian Enterprises

Enrollment Form

Name ____________________________________ Title ______________________________

Branch __________________________Agency/Tribe_________________________________

Address______________ _______________________________________________________

City ___________________________________ State _____________ Zip ________________

Phone _______________________________ Fax ____________________________

Email Address _________________________________________________________________

Courses you wish to enroll in:

1.___________________________________________________________________________

2.___________________________________________________________________________

Payment Method (check one):

Check ____ VISA ____ Mastercard ____ American Express ____ P.O. _______________________

Credit Card No. _________________________________________Exp. Date ________/________

Print your name the way you would like it to appear on a certificate:

_____________________________________________________________________________

Please mail or fax this form to: ICC Indian Enterprises

PO Box 217

Berlin, NH 03570

603 752-0014

fax 310 765-4992

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