Mailing Address

Zip Code

Work Phone Number

Payment Method
(We do not accept credit cards at this time)

If paying by Charge Code, please provide the following additional information:

Name of Company and Department
that is paying for the course
(example: BPX or Conoco Phillips, medical, spill, fire department)

What is the Charge Code?

Name of the person approving you to attend the course
(Head of the Department, i.e. PA, Fire Chief, Spill Tech, Manager, Direct Supervisor)

Approver's Phone Number

If MultiMed is billing your company direct without a Charge Code,
please also provide the following information:

Company Name

Company Billing Address

City

State

Zip Code

Approving Supervisor Name

Supervisor's Phone Number

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