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Dixon
800 High Street
Chestertown, MD 21620
410.778.2000 phone
410.778.4702 fax
dixonvalve.com
Dixon Hose Coupling Workshop
Registration Form
Distributor Information:
Company Name:
Street:
City, State, Zip:
Email:
Cust ID (Internal):
Class Location:
Dixon Valve & Coupling Company
40 Chestnut Ave
Westmont, IL 60559
Phone: 800-355-1991
Class dates: (This is a one-day workshop; please enter date in the following
attendee table)
Tue – April 22, 2014
Wed – April 23, 2014
Thu – April 24, 2014
Attendees: Please Print Clearly for certificates & name tags
1.
2.
3.
4.
5.
6.
Cost per Student $50.00
(includes continental breakfast & lunch)
Purchase Order # ______________________________
Authorized Manager: ______________________________
(please print)
Registration DEADLINE: Monday, April 7, 2014
Classes will be filled on a
first-come, first-served
Name
basis
Date
Requested
Please email to cnugent@dixonvalve.com or
fax to:
1-800-283-4966
Attn: Cherie Nugent
T-Shirt
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