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Student Registration Form

Full Name(*)

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Company Name

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Address(*)

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City(*)

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State(*)

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ZIP(*)

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E-mail(*)

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Phone Number(*)

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Emergency Contact Name

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Emergency Contact Phone Number

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Credentialing Tracking Number(*)

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* The number requested by credentialing organizations is the last four digits of your Social Security Number, however, any four numbers will be sufficient. The tracking number must be consistently used for all industry training program for proper credit to be applied.

For purposes of training verification, AGC requires permission to disclose the following information to industry credentialing organizations,

Name
Tracking Number
Final exam score

How long have you been in the auto glass industry?

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How many years of experience do you have in auto glass replacement?

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How many years of experience do you have in auto glass repair?

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Are you familiar with auto glass tools?

Yes

Please specify your familiarity with glass tools

Do you have any prior training in auto glass repair and/or replacement?

Yes

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Please check below which best describes your job description

Class Date and Location(*)

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Payment Method ($1200 Tuition)(*)

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