Food Manager Certification Registration Form
(Note: Class sizes are limited, so please register early. Use one form for each registrant.)

Please complete the form and mail it with a check or money order to:
American Food Safety, 2734 North 5th St, Philadelphia, PA 19133,
or you may register by phone with your Visa or MasterCard by calling 1-(800) 723-3873 or faxing (215) 634-6184.


Student Name: ________________________________________
Student Address: ________________________________________
Daytime Phone: ( __________ ) _________________________
Business Name/City: ________________________________________
Fax #: ( __________ ) _________________________
Course Language: English _____ Spanish _____ Chinese _____
Course Location (City & State): ________________________________________
Course Date: __________________
Amount Enclosed: __________________
Billing Information: Name on Card: ________________________________
Visa or MasterCard #: ________________________________
Expiration Date: __________________
Signature: __________________________________