Center for Information Security Research and Education
Certificate Program Registration Form
University of Houston - College of Technology
3-Day SCADA Security Certificate Class
May 10, 11, 12 2016
Registration deadline: May 6, 2016
Note: No Refunds. All Registrations are Final.
Price for Each Course is $1800.00
Packages and multi-person discounts are available, contact Sandra Bazan, 713-743-4236 or SMejia@Central.UH.EDU for details.
This Form must be faxed to the Secure Fax line to complete registration 713-743-9619
Participant Information
First Name:
Last Name:
Home Address:
M.I.:
City:
Phone:
Male
State:
Female
Zip:
_ Email: _______________________
Please return ONLY this page by fax to 713-743-9619 or mail to:
CISRE
University of Houston
College of Technology
309 Technology Building
Houston, Texas 77204-4021
DO NOT EMAIL
UNDER ANY
CIRCUMSTANCES
---------------------------------------------------------------------------------------------------------------------------------------------------------Please indicate your method of payment:
Check - Personal or Cashier’s Check made payable: University of Houston – (DO NOT send cash through the mail)
□ MasterCard
Credit Card Number:
Print name on card:
□ VISA
□ AMEX
□ Discover
(please check one)
Expiration Date:
(MM/YY)
Signature:
A receipt (redacted) will be emailed to you at the time of payment. Originals will be available upon request.
Please forward registration and availability questions to: Sandra Bazan, 713-743-4236 or SMejia@Central.UH.EDU