Wiring Motors and Air Conditioners - 2014 Code (8 hour course) Class Sign Up Form Location: Online Classes   Class Instance ID: 7174 Document ID: 566D

If you need to register with the state as an Electrician Trainee and you are enrolling with WECA for the first time or you are re-enrolling, please complete an ET program enrollment and initial class sign up form (Form Link: http://goweca.com/files/ETEnrollmentandInitialClassInfoandForm.pdf).

* I am a(n):

Electrician Trainee    Certified Journeyman     General Student

/       /            First Name*                             Middle Initial*              Last Name*                                      Date of Birth*
Mailing Address*	Apt #*                  City                            State                                Zip*
Primary Phone* Home  Cell   Other   Secondary Phone* Home   Cell   Other SSN*
Highest grade level completed* Ethnicity/Race Email Address Gender: Male Female How did you hear about us? State Issued ID#
Preferences (Please choose one option from each of the following categories)
Class Location: Rancho Cordova San Diego (*Get Wired - applies to on-site classes) Language: English Spanish Other Preferred Contact Method For Correspondence (If you do not select your preferred correspondence method, the default will be set for regular mail): (For Class Schedules, Enrollment Confirmation Letters etc.) Email Mail Fax
Are you currently employed by an Electrical Contractor?    No    Yes If yes, complete the following:
Contractor Name*	Contractor Phone Number*
Contractor Mailing Address*                    City                              State                                                       Zip*
If you are signing up for a Live Web Cast (LWC):   Students must have an email address Have you reviewed the system requirements for the class? Yes    No

X		/       /
Signature		Date

Payment Method: Cash    Check**    Money Order**    Visa    MasterCard				Coupon Code
** Make payable to WECA. There is a $25 fee for all returned checks.

		/20
Credit Card Number		Expiration Date		3 Digit Security Code

Print name exactly as it appears on credit card		Cardholder's Full Billing Address

X		/        /		$
Charge Authorization Signature		Date		Amount Authorized