Name                 SSN        

 Company           Title   

 Address              City   

 State                   Zip    

 Phone                 Fax   

 Email       

                                                   Method of Payment:

□ Check (payable to OSU CEAT Continuing Education)
□ Money Order (payable to OSU CEAT Continuing Education)

□ Invoice Company FEI# (Required) 

□ MC/Visa#           

Expiration Date        Cardholder's Name   

Authorizing Signature

Oklahoma State University is the sole sponsoring entity for this Fire Protection Certificate program and therefore does not claim accreditation or certification under any other pretenses where Fire Protection Certificate is concerned.  We have the right to change course instructors, to revise courses and change textbooks, to discontinue courses, and to adjust tuition and materials cost listed as circumstances warrant.

 By signing below, I understand and agree to the guidelines of this program.  I also understand that Oklahoma State University is the sole sponsoring entity offering this certificate program and does not claim accreditation or certification under other pretenses where this certificate is concerned.

Applicant’s Signature   Date