Name :
__________________________________________________________________________________
(last)
(first)
(middle)
Company/Organization : _________________________________ Title :
__________________________
Address :
________________________________________________________________________________
__________________________________________________________________________________________
Phone :
_________________________________________________________________________________
(daytime)
(mobile/evening)
E-mail :
___________________________________________________
I want to get the optional Linux laptop (additional
$500 in the course fee)
Please write a check or
money order for $349 ($849 if Linux laptop is included)
payable to "LinuxCertified, Inc." (unless paying by credit
card), and send it with this enrollment form to:
LinuxCertified,
Inc.
1072 S. De Anza Blvd., Suite A107-19
San Jose, CA 95129
Payment by
Credit card: Card number:
___________________________________
Expiration: ________________
Card type (circle one): Visa Mastercard
American Express
Name on the Credit card: ________________________________________________
CID/CVV2 number:_____________(4 digit number
on top of AMEX or 3 digit number at the end of signature
panel of Visa/Master Card/Discover)
Signature: ___________________________________ Date:
_____________________
Credit Card Billing
address:_______________________________________________
_________________________________________________________________________
If paying by credit card, you can also fax the form to (425) 732-7143
Please do notify us via email when sending the form.
I have read and I agree to the Terms and Conditions listed on website of
linuxcertified.com
Signature_________________________________________
