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| Dept: |
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| Email Address: |
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| Email Address 2: |
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| Supervisor Name: |
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| Title: |
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| Organization: |
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| Billing Dept: |
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| Address: |
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| City: |
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| State & Zip/Postal Code: |
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| Phone: |
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| Fax: |
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| Course Title: |
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| Course Start Date: |
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| Expense Reduction Package? |
No Yes |
| X # of Days: |
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| Smoking? |
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| METHOD OF PAYMENT: |
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| If Direct Billing, P.O. Number*: |
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| If Check: |
Make check payable to DITEC, Inc. |
| If Credit Card: |
Card information will be taken over the phone. |
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| * All purchase orders will be assessed a $25 invoice processing fee. |
| All invoices will be assessed 1.5% per month (18% per annum) late fees when thirty or more days past due. |