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FSMA COURSE REGISTRATION FORM

Company Data

Company Name

Field of Work

Address

Phone:

Fax

Candidate Data

Name and Surname

Date of Birth

Place of Birth

EIN or FEI or SSN

Position/Qualification

Personal Email

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Organizing Committee

ITA CORPORATION

6300 Blue Lagoon Dr. Suite 400

Miami Florida, USA

Tel: +1.347.964.0171

Mail: info@itacorporation.org

INSPECTION TRAINING AUDITING CORPORATION

MIAMI FL 33156 USA

Bank details for Wire Transfer:

Bank: CITYBANK N.A

Account Number: 9145092468

ABA/Routing Number: 266086554

The FSVP Course fee is $900

Payment receipt

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The total payment must be made viawire transfer 30 days prior the course start date. A copy will have to besubmitted to the Admin Dept. In case of cancellation 15 days prior thebeginning of the course, the candidate will be reimbursed 50% of the amount paid. Past this date no refunds will be processed.