Perl Training 101 - Class Enrollment Form

Contact Information

Name : __________________________________________________________________________________
        (last)                                      (first)                                           (middle)

Company/Organization : _________________________________ Title : __________________________

Address : ________________________________________________________________________________


Phone : _________________________________________________________________________________
                         (daytime)                                                  (mobile/evening)

E-mail : ___________________________________________________


Class Preference

Please check the class you will prefer to attend.

  Currently not scheduled  (San Jose)         

How did you hear about us ? _________________________________________________________________


Registration Fee

I want to get the optional Linux laptop (additional $500 in the course fee)

Please write a check or money order for _____ (_____ 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


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