Lewis & Clark Community College- Bethalto Training Center www.lc.edu/safety
1136 E. Airline Drive Main: (618) 468-5782
East Alton, IL 62024 Fax: (618) 468-7514
1136 East Airline Dr., East Alton, IL 62024
HASC Account Number (if available): __________________________________________
Company Name:
Address: City, State, Zip:
Contact Person: Phone:
Fax: Email:
LCCC Covid-19 Re-opening: Due to safe distancing guidelines, Pre-registration is required (No walk-in service available at this time)
MASKS must be worn in the building at all times
Payment
Must Be Made In Order to Secure Your Employee’s Registration for Training.
- Credit
Card information may be given over the phone by calling Jennifer (618) 468-5782 or Dawn (6
18) 468-5785 or
Credit
Card
Ty
pe:
□ VISA □ MASTERCARD □ AMERICAN EXPRESS □ DISCOVER
Card Number:
Exp. Date VIN#
Name on Card:
Signature:
Your signature authorizes the below specified training and for Lewis and Clark to apply the charges for this training to
t
he g
iven credit card.
REGISTRATIONS MUST BE RECEIVED NO LATER THAN 12:00 PM THE DAY PRIOR TO TRAINING.
RETURN FORM via Fax (618) 468-7514 Or Email to jdriskell@l
c.edu
Please see our website, www.lc.edu/HASC_satellite, for course listings/codes.
Training Date Requested: (Use a separate form for each day of training)
TRAINEE COURSE
Social Security Number Last Name First Name Course Code
