Online forms: BETA Registration & Payment Form

1. First Name Required

2. Middle Initial

3. Last Name Required

4. Additional Name

5. Birth Date Required

6. Are you a US Citizen / Permanent Resident? Required

Yes No

7. Gender Required

Male Female

8. Permanent Address Required

Business Address Personal Address

9. Street Required

10. City Required

11. State Required Please select ... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

12. Zip Required

13. Phone Required

14. Alt Phone

15. Email Required

16. Would you like to be notified of upcoming training opportunities? Required

Yes No

17. Are you Hispanic or Latino? Required

Yes No

18. What is your race? Please select one or more Required

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

19. Are you a Butler Community College Employee? Required

Yes No

20. How did you learn of BETA and our course offerings? Required

Advertisement Billboard Direct Mail Employer Event Facebook Friend/Referral Internet Search/Website LinkedIn News Article Newsletter/Email Radio Twitter

21. Register in the following courses

Required Course Offered	Course Date
Course Offered 1	Course Date 1
Course Offered 2	Course Date 2
Course Offered 3	Course Date 3

22. PERSONAL PAY

Check Cash Credit

23. COMPANY PAY

Check Cash Credit

24. Company Name

25. INVOICE NEEDED? Required

Yes No

26. REFUND POLICY A full refund is given if BETA cancels a class OR if a participant withdraws at least 7 days prior to the date of the class. A refund, less a $20 Processing Fee, is given if a participant withdraws 2-6 days prior to the date of the class. No refund is given if a participant withdraws less than 48 hours prior to the date of the class. PAYMENT POLICY Registration constitutes responsibility for payment. Payment by cash or check must be received 7 days prior to the date of the class, unless secured with a credit card. If your employer or organization declines to pay for the class for any reason, you are responsible for payment. Required

I HAVE READ AND UNDERSTAND THE BETA REFUND & PAYMENT POLICY STATEMENTS