Credit Card # ______________________________________________________
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Mail to address on form or FAX to 912-882-1399.
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20013/2014 Septic Tank Class Registration Form
______________________________ _________________________________________________________
Name
Certification Number
__________________________________________________________________________________________
Mailing Adrress
City
State
Zip Code
____________________________________________ ___________________________________________________________
(Area Code) Daytime Telephone #
E-mail Address
Class Date_______________________________________ Class Location(City)____________________________________________
$125 ($100 pumpers)
Add $20 for GSWCC Card
SBTA
P.O. Box 468
St. Marys, GA 31558
Payment Method: ________ Enclosed
OR
Please charge to:_______Visa_______MasterCard______American Express
Expiration Date___________________________
Print Name
exactly
as it appears on credit card___________________________
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