Name:

Company Employed By:

Address 1:

Address 2:

City:

State:

Zip Code:

E-Mail:

Phone #:

Fax #:

Course Name:

Course Date:

Purchase Order #:

Approving Supervisor’s Name:

Approving Supervisor’s Phone #:

Comments:

Fee: $300.00 per day for each student. Purchase order # for the amount of the entire class must be received with the enrollment application. Payment for the entire class must be sent to Covington Diesel prior to the scheduled class date.

Note: This is only an application for admittance to the class requested above. As attendance is limited for each class, this application will be reviewed for space availability as well as the applicant’s compliance with being employed by an approved Covington dealer or customer.

Acceptance of this application will be sent to applicant organization via e-mail.