Safety Registration Form Events and Class Registration (Please fill out form for each class. Classes are closed out one week prior to class date.) ONLINE = ONLINE ONLY FROM ANY ISLAND All class books will be mailed except for Oahu. Companies will be charged for the postage of books. Please allow 5 business days for mail Please choose one or two of three classes available. Driver Improvement: Member Price - $45, Non-Member Price - $75 and/or Online or (In HTA Classroom) PLEASE NOTE NEW ADDRESS FOR IN CLASS ON CALENDAR. WALKINS NOT ACCEPTED Hazardous Materials Training: Member Price - $40, Non-Member Price - $70 and/or Online or (In HTA Classroom) PLEASE NOTE NEW ADDRESS FOR IN CLASS ON CALENDAR. WALKINS NOT ACCEPTED Forklift Training (classroom): Member Price - $40, Non-Member Price - $70 Online or (In HTA Classroom) PLEASE NOTE NEW ADDRESS FOR IN CLASS ON CALENDAR. WALK INS NOT ACCEPTED Road Evaluation Member Price: $70, Non-member Price - $110 Pre Trip Coaching for License Upgrade (2 hrs): Member Price - $140, Non-member Price - $220 (AirBrakes not included)Pre Trip Coaching for License Upgrade (2 hrs): Member Price - $140, Non-member Price - $220 (AirBrakes not included) Forklift Evaluation: Member Price - $30, Non-member Price $60 for first forklift; additional $20 for member/$40 for non-member (Classes 1 - 6) Class 7 - Forklift Evaluation: Member Price starting from $60, Non-member Price from $90 Companies will be charged for All students who are confirmed for the classes regardless of actual attendance, unless two working days notice is given on attendance. For Heavy Equipment Training, License Upgrade and Formal Training, please contact Lynn at (808) 833-6628 or email at [email protected]. NO SHOWS will be given one chance to make up the class at no additional charge on a space available basis within the calendar year. When rescheduling the "free makeup class", please indicate on the side of their name, date of the class that individual missed (e.g. Joe Smith, n/s 1/1/14) Date * Company Name: * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Telephone Number (please enter without dashes or commas; can include area code) * Please indicate best day-time phone number to contact. Email * Name (First and Last Name) * Payment Amount *Request for billing option (HTA members in good standing only) Please invoice me Credit Card form attached - 2% surcharge to be applied Mailing in payment Please indicate Name of Drivers and Email address required for online training Name (First and Last Name) Email Name (First and Last Name) Email Name (First and Last Name) Email Name (First and Last Name) Email Name (First and Last Name) Email Add More Remove If you selected to pay via credit card, please click the following link and complete as required: Credit Card Payment Link Captcha Submit
