ServSafe Food Manager Class & Examination 2 Day Class

Allen County Extension Office 4001 Crescent Ave

Fort Wayne, IN 46815 East Side of IPFW Campus

Sept. 12 & 19 Registration: 8:00 AM - 8:30 AM

Class: 8:30 AM - 5:00 PM Exam: 3 PM on the 19th

For questions or more information contact InRLA at (317) 673 - 4211

REGISTRATION FORM: Confirmation will be sent once received. Exam results and certificate will be mailed to the name and address listed on this form from the National Restaurant Association.

ATTENDEES 1. ____________________________ 2. _________________________________________ 3. ________________________________________ 4. ________________________________________ COMPANY ________________________________ CONTACT _________________________________ EMAIL _____________________________________________ PHONE __________________________ ADDRESS __________________________________CITY________________STATE ___ ZIP ________

ITEMS QTY AMT

Class, Exam & Book: $165

Exam Only: $60

Book Only: $65

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MAIL TO: Indiana Restaurant & Lodging Association, 200 S. Meridian St., Suite 350,

Indianapolis, IN 46225 OR REGISTER ONLINE AT INRLA.ORG

DISCOUNTED RATES: Class, Exam, Book $145 / Exam Only $50 / Book Only $55

This rate applies to InRLA members & not-for-profits ONLY

Check here if special accommodations needed (pre-registration required) ________

Please indicate number of textbooks needed other than English: __ SPANISH OR ___ CHINESE Please indicate number of exams needed in following languages other than English:

__ Spanish __ Korean __ Chinese __ Japanese __ French Canadian __ Instructor __ Large Print

PAYMENT: ___ Check Enclosed (Make checks payable to Indiana Restaurant & Lodging Association)

___ AmEx CARD NUMBER _______________________________ EXP. DATE _______________

___ Mastercard CVV CODE _______ SIGNATURE __________________________________________

___ Visa ADDRESS _____________________________________________________________REFUND POLICY: If you are unable to attend class after payment is made, you may transfer to any other class one time without penalty or request a refund. All refunds will be distributed less a 10% administrative fee minus the cost of any supplies mailed. LATE FEE: If registering less than a week out from a class, a $20 late fee will be applied to your total.

A photo ID with signature is required to take the exam. (e.g., driver’s license, state ID, student ID, military ID, employee ID, U.S. green card, or valid passport)