NDGAA ONLINE WORKSHOP & CERTIFICATION PRE-REGISTRATION FORM
*Please fill in the location that you are pre-registering for (check for event location & date on our Event Schedule
*Fill out the Form in full.
*Complete the payment section and hit the SUBMIT

Pre-Registration Workshops

PERSONAL INFORMATION

  * Required Information    Use Tab Key to Navigate Form
*First & Last Name:    
NDGAA Member Number (if any):    
*Street Address:    
*City:    
* State/Prov:     
*Postal Code:      
*Country:    
*Date of Birth:    
*Your Cell Phone:    
*Your Email Address:    

Mail Any NDGAA Materials to:

  My Home Address  My Salon Address
     

*Salon Name:

   
*Salon Street Address    
*Salon City, State, & Zip:    
*Salon Phone:    
*Salon Website:    
*Your Position:    
*How Long in Business?    

*Type of Facility - Land Base or Mobile?

   
     
*Testing / Workshop Location State:    
*Event Date:    
     
    Full Workshop – $125 Non-Member fee
Full Workshop – $110 Member fee
Non-Sporting $125   Sporting $125
Terrier $125 (2 Terriers + Written/Practical Test)    
     
MEMBERS ONLY:   Long Legged Terrier $75
    Short Legged Terriers $75
    Non-Sporting Written $60
    Sporting Written $60
    Terrier Written $60
    Master Exam $125
     

  Breed Study Kit

NDGAA Breed Profile Study Kit – $45

     
     

How Do You Propose to Pay?

 
Proposed Payment Method Credit Card Online  Credit Card By Fax
Mailing Check/Money Order

Type of Credit Card to process?

 
Credit Card Visa  
MasterCard
American Express
Discover

Credit Card Number:

   
Name on Credit Card:    
Billing Street Address for Card:    
City:    
State/Prov:    
Zip/Postal:    
Country:    
Expiration Date - (Example 05/12)        Security Code (CVS)  
Charge Authorization, Your Consent and Electronic Signature

PAYMENT & LIABILITY AGREEMENT I am in agreement and hereby authorize NDGAA to charge my credit card in the amount of $ in payment for my Pre-Registration fees. Your Name -   by typing my name I hereby agree that neither NDGAA, nor the event host hotel or business, their sponsors, agents, employees, or representatives shall be liable for any loss, damage, harm or injury to the property or person of the applicant or its representative resulting from fire, accident, theft or other causes. Attend at your own risk - I/We hereby agree that I/We have read and understand this policy, and I/We Hereby Acknowledge that having read and understand the limits of liability for this event I/We agree to the risk liability. Please click the SUBMIT tab once you have completed all information. By typing my name and entering the total fees to be charged to my credit card, I agree this will serve as my Electronic Signature.

 

THIS FORM IS VERY - VERY SLOW TO SUBMIT
PLEASE WAIT FOR A COPY OF YOUR ORDER TO APPLY ON THE SCREEN.

Once you click the Submit tab
it takes about 20-25 seconds for
the data to submit - please be patient

We accept Visa, MasterCard & American Express
P.O. Box 101,   Clark, PA 16113 - Ph.  (724) 962-2711 - Fax  (724) 962-1919

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