PEC Infectious Disease Preparedness Module

PEC INFECTIOUS DISEASE PREPAREDNESS ELEARNING MODULE

Your registration will be placed with:

Your Safety Department, LLC

La Vernia, Texas 78121

Phone: 888-859-5653

NOTE: The cost of the PEC INFECTIOUS DISEASE PREPAREDNESS MODULE is $30.00

PEC INFECTIOUS DISEASE PREPAREDNESS ELEARNING MODULE

CONTACT INFORMATION

First Name*

Last Name*

Cell Phone Number*

Work Phone Number:*

Email Address*

TRAINEE INFORMATION

First Name*

Last Name*

Last 4 of SSN#*

Date of Birth*

PEC ID Number

Former Employer (If Applicable):

Current Employer (To appear on new card):*

Is this a change of employer?* No Yes

Current Employer HR Representative Email*

Additional Information

I authorize PEC to contact my current employer for verification. PEC cards will be mailed via US Mail unless otherwise specified. I authorize*

MAILING ADDRESS

Mail Address Type* Residence Company

Name:*

Address 1:*

Address 2:

City*

State*

Zip Code:*

CREDIT CARD INFORMATION

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