Text Box: REGISTRATIONS ARE ON A FIRST COME-FIRST SERVE BASIS ONLY.  NO REGISTRATIONS WILL BE 
ACCEPTED WITHOUT CHECK, CASH OR CREDIT CARD.
YOUR REGISTRATION WILL BE CONFIRMED BY MAIL. 
MAKE CHECKS PAYABLE TO ST. PAUL ELECTRICAL JATC AND MAIL OR DELIVER TO: 
ST. PAUL ELECTRICAL JATC, 1330 CONWAY STREET, SUITE 150, ST. PAUL, MN  55106
OFFICE PHONE NUMBER:  651-772-8746

OR REGISTER ON-LINE AT:  www.ibew110.org/jatc
           PLEASE PRINT:
 NAME_______________________________________________________________________                          
First                                    Middle                                                    Last Name
ADDRESS ________________________________________________________

CITY, STATE, ZIP        ______________________________________________

           LAST FOUR DIGITS OF SS#:  __________  PHONE # _________________		
          JW STATE LICENSE #:  ________________   EXP. DATE  _______
           MASTER LICENSE #:    ________________   EXP. DATE  _______

       IBEW LOCAL #110 CARD NUMBER:  ____________________  CURRENT CONTRACTOR:  ________________
       IBEW LOCAL #292 CARD NUMBER:  ____________________  CURRENT CONTRACTOR:  ________________
       IBEW LOCAL #343 CARD NUMBER:  ____________________  CURRENT CONTRACTOR:  ________________

       IBEW MEMBER—LOCAL UNION CARD NUMBER:  ____________  LOCAL UNION #:  __________________

PLEASE CHECK THE APPROPRIATE BOX BELOW IF IT APPLIES TO YOU:
RETIREE__________  ON PARTICIPATING WITHDRAWAL__________ ON DISABILITY__________
______ESTIMATOR/PROJECT MANAGER –  CONTRACTOR________________	

IF PAYING BY CREDIT CARD:    AMOUNT  ON CARD:  _______________

NAME AS ON CARD:  ___________________________________________ CARD TYPE:____________

CARD NUMBER:______________________________________________CARD EXP. #:_____________ 
3 DIGIT NUMBER ON BACK OF CARD (IF LEGIBLE)___________________

 




IF REGISTERING FOR NEC UPGRADE CLASS PLEASE INDICATE 1st and 2ND CHOICE FOR CLASS DATE.   IF YOU DO NOT RECEIVE CONFIRMATION BY MAIL TWO WEEKS  PRIOR TO YOUR CLASS START DATE, PLEASE CALL THE JATC OFFICE.
Text Box: FOR OFFICE USE ONLY:
PAID BY CASH:  AMOUNT______________    PAID BY CREDIT CARD:  AMOUNT____________ PROCESSED ON:_______________

PAID BY CHECK:  AMOUNT:  ________________  CHECK NUMBER:  ________________  CHECK DATE________________

COURSE TITLE

START DATE