Lean Six Sigma Green Belt Blended Training Registration Form

Lean Six Sigma Green Belt
Blended Training Registration Form
Join ASQ to receive the member rates on your courses.
To complete your registration and purchase:
• In order to serve you better, please fill out this form completely.
• Your registration (whether phoned, faxed, or mailed in) will
be confirmed by mail with a receipt and separate confirmation
letter. We will make every effort to process your registration
within two business days.
• If you haven’t received your confirmation within two weeks of
sending your registration, or if you need to make any changes,
please contact ASQ.
Select the Web-based course that you are registering for.
❑ I learned about the course/seminar(s) I’m registering for
through ASQ’s website.
❑ I learned about the course/seminar(s) I’m registering for
through a publication that has this PROMO CODE on it.
Promo Code
Member Number:
Your member number is required for member price.
First Name for Badge:
Last Name:
First Name: Middle Initial:
Name of Company:
Title or Department:
COURSE FEE: ❑ Member Price:
$3,499 ❑ List/Forum/Division Price: $3,899
❑ Lean Six Sigma Green Belt — Traditional Version
❑ Lean Six Sigma Green Belt — Healthcare Version
❑ Lean Six Sigma Green Belt — Services Version
December 6, 2016 – Virtual Session 1
10:00 a.m. – Noon – Central Time Zone
The week of December 12, 2016 – Individual Coaching
January 3, 2017 – Virtual Session 2
10:00 a.m. – Noon – Central Time Zone
The week of January 9, 2017 – Individual Coaching
February 6 – 8, 2017 – 3-Day Classroom Course #9832BLD
8:00 a.m. – 5:00 p.m. – Central Time Zone – Daily
The week of February 13, 2017 – Individual Coaching
February 21, 2017 – Virtual Session 3
10:00 a.m. – 1:00 p.m. – Central Time Zone
(3-Day Classroom Portion of the Course)
Premier downtown location on Milwaukee’s riverfront
in ASQ Center: ASQ (American Society for Quality)
600 North Plankinton Avenue
Milwaukee, WI 53201
❑ Home ❑ Business
Street Address:
❑ I understand that my best learning experience will come from
“NA” if state and/or postal code are not applicable.
Please submit your order with payment (to submit, a P.O. must be
printed on company letterhead) via one of the following options:
• Call our Customer Care Center to place your order with a live
agent. Monday – Friday 7:00 a.m. – 5:00 p.m. Central
– North America: 800-248-1946 (United States and Canada only)
– Mexico: 001-800-514-1564
– All other locations: 1-414-272-8575
• Fax to: 414-272-1734
• Mail to: American Society for Quality P.O. Box 3005 Milwaukee,
WI 53201-3005
For your protection, email transmittal is prohibited.
Zip/Postal Code:
participating in this course the way it was designed—to form a cohort
that progresses through the content together, to create a cohesive
experience throughout, and to partner with the instructor. Therefore,
I agree that transferring to/from any of the virtual or classroom
sessions is not in my best interest and will not be permitted. (SVY1)
ORDER TOTAL _____________
Daytime Telephone Number:
❑ Check or money order (U.S. dollars drawn on a U.S. bank).
Make check payable to ASQ. Check Number: ___________________
Fax Number:
❑ Company-issued purchase order (hard copy on company letterhead must
accompany registration form). Verbal POs are not allowed.
Purchase Order Number * ___________________
I would like to receive information about ASQ via email.
❑ Yes
❑ No
Do you have any special needs, disabilities, and/or dietary restrictions
that you would like us to address?
❑ ACH/WIRE payment. Please contact Customer Care if choosing this option.
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