EDR Registration Form

EDR On-Line Training Registration Form

* Required fields are indicated with an asterisk *.

Are you employed by a state agency within the Commonwealth of Virgina? Only Virginia state employees are eligible to register on-line (a printable registration form is available below for "non-state employee" registration). *		yes no

First Name *:	Middle Initial:
Last Name*:
Job Title *:
Are you a supervisor? *	yes no
Email Address:
Telephone Number *:	Area Code: ( ) Number: - Ext:
Fax Number:	Area Code: ( ) Number: - Ext:
Agency*:
Facility:
Address *:
Course Title*:
Date*:	Time*:
Location*:

Method of Payment: (This area must be completed if applicable)
IAT Agency #:
Billing Address:

By registering online, you indicate that you have obtained the necessary agency approval to participate in this training course. Do you wish to continue with your registration?* yes no
Approval given by *:
Approval Title * :
Approval Tel Num *:	Area Code: ( ) Number: - Ext:
Approval Fax Num *:	Area Code: ( ) Number: - Ext:
Approval Email :

If accommodation for a disability is required, please specify:

Print Registration Form for Manual Preparation

Confirmation of Received Registrations

Confirmations will be sent to the registrant and supervisor via email, or, if email is not available, by fax. The agency will be billed via IAT at the conclusion of the course.

Cancellation/Refund Policy

Your written cancellation (email: training@edr.virginia.gov, fax: (804) 786-0111, or mail) must be received at least two weeks prior to a scheduled course to receive a refund or credit toward another course. Failure to cancel two weeks in advance or to show for a course will result in the full fee being charged.

EDR reserves the right to cancel scheduled courses due to low registration. An attempt will be made to contact you via the information provided on your registration form if a course is cancelled or full.

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