Electrical Apprenticeship Training Program TECA 2012-2013 ...

Associated Builders and Contractors5505 Robin Hood Road, Suite DNorfolk, Virginia 23513Tidewater Electrical Contractors AssociationElectrical Apprenticeship Training ProgramPreparing Individuals for Exciting Careers and Life-Long Learning Opportunities.TECA APPRENTICESHIP REGISTRATION 2012-2013 SESSIONStudent_______________________________________________________Birth Date _____/_____/_____Student Email Address________________________________________________________________________Social Sec. # __________-________-__________Home Phone ____________________________________Address ______________________________________ City ____________ State _____ Zip ________Employer __________________________________Employer Contact _____________________________Business Phone _________________ Business Fax ___________________Business E-mail________________Employer's Address _____________________________ City ____________ State _____ Zip ________TECA Class Level: Level One Level Two Level Three Level FourNote: A registration form must be completed for each individual apprentice. Registrations must be received no later than August 3, 2012.PAYMENT OPTIONSAPPLICATIONS ARE PROCESSED ON A FIRST-COME, FIRST-SERVED BASIS, AND WILL NOT BE PROCESSEDUNLESS ACCOMPANIED BY PAYMENT. CHECKS SHOULD BE MADE PAYABLE TO ABC-VA.I AM SENDING A CHECK MADE PAYABLE TO ABC-VATO 5505 ROBIN HOOD ROAD, SUITE D, NORFOLK,VIRGINIA 23513PLEASE CHARGE MY VISA/MASTERCARD/AMERICANEXPRESS. (3% charge on all credit card payments).ABC-VA Phone Number: (757) 855-8220ABC-VA Fax Number: (757) 855-8225Name ______________________________________Card Number ________________________________Verification Code_____________________________Expiration Date ___________Billing Zip___________Signature ___________________________________