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: __________________________________