Registration Form for the Stack Sampling & CEMS Workshop

For the next Date of the workshop Call me at 919-772-7843 or email me at walt@waltersmith.com 

Workshop Date ________________Location_________________________________________

  • Name: _____________________________________________________________
  • Title: _______________________________________________________________
  • Company: ___________________________________________________________
  • Address: ____________________________________________________________
  • City: ___________________________________ State: ______  Zip: ____________
  • Phone: _______________________ ex___________  Cell:_____________________
  • Email:_______________________________________________________________

Please select method of payment (No purchase orders, please) (Check one):

  • ____VISA  ____MasterCard ____American Express  ____Discover ____Check Enclosed
  • Card Number: __________________________ Expiration Date: ____/____/_______ CVV: _________
  • Authorization Signature: __________________________ Print Name: _________________________
  • $1299.00us

If using a credit card, copy filled out form and email to walt@waltersmith.com

If sending a check, send to:

  • Walter Smith & Associates, Inc.
  • 6225 Splitrock Trail
  • Apex, NC 27539