Registration Form for Certified IAQ Manager (CIAQM) Online Course
(This is not the application for the CIAQM Certification Exam)
TO REGISTER, PRINT OUT THIS FORM AND FAX OR MAIL BACK TO INDOOR SCIENCES, INC.

1. Fill out the Registration Form for Certified IAQ Manager Online Course.
2. The Registration Form must be signed and dated by the applicant. It should be submitted with course fees.
3. This Registration Form, remittance, and all correspondence should be directed to:

Indoor Sciences, Inc. • 105 W. Madison St. • Ste 802 • Chicago, IL 60602 • Fax (312) 637-9393

5. There are no prerequisites for the CIAQM Course
Note: There are prerequisites for CIAQM Certification. Details and the CIAQM Exam Application are available by contacting the American Indoor Air Quality Council (AmIAQC) at 1.800.942.0832.

Certified IAQ Manager (CIAQM) Online Course Registration Form
Your Name _______________________________________________________________
Company Name _______________________________________________________________
Address _______________________________________________________________
City _______________________________________________________________
State _______________________________________________________________
Zip _______________________________________________________________
Daytime Phone _______________________________________________________________
Fax _______________________________________________________________
E-mail _______________________________________________________________
FEES
Course Fees IAQA Members -- $625 Non-Members -- $750

This Registration Form is for the CIAQM Course only. This is not the application for the CIAQM Certification Exam. Please contact the American Indoor Air Quality Council (AmIAQC) at 1.800.942.0832 for CIAQM Certification prerequisites, exam application, and exam fees.
Make checks payable to "Indoor Sciences, Inc. "  Or pay by credit card by completing below:
 
Credit Card (circle one): VISA    MasterCard    American Express
 
Amount to Charge $____________
Card Number ________________________________________________
Expiration Date ____________________
Name on Card ________________________________________________
Billing Address ________________________________________________
________________________________________________
Signature ________________________________________________

Cancellation and Refund Policy: The CIAQM Online Course is non-refundable and non-transferable. You can request transfering your registration to an on-site CIAQM course, which will be awarded on a case by case basis.

Applicant Signature _________________________________ Date_______________
RETURN THIS FORM AND PAYMENT TO:

Indoor Sciences, Inc. • 105 W. Madison St. • Suite 802 • Chicago, IL 60602
Phone (312)920-9393 •  Fax (312)637-9393