Welcome to the TrainSafe program brought to you by Southern Research and Behavioral-Based Improvement Solutions.

Completing this form will provide your contact information to us and allow us to contact you when the dates of a course you are interested in are available.  Completing this form DOES NOT mean you have been accepted to the program.

These courses are offered multiple times a year at a cost of $2,000 per individual. All classes are held at Southern Research's Birmingham, Alabama, location. If you are interested in taking the course, please fill out the form, below, to receive more information, including a full schedule.

We will contact you when a spot is available and if you are interested  - will invite you to apply to an upcoming training event.  If you have any questions, please contact Sean Kaufman at 404.849.3966.

Thank you.

* 1. First Name:

* 2. Last Name:

* 3. Professional Organization:

* 4. Phone Number:

* 5. Which TrainSafe Course are you interested in attending? (select all that apply)

* 6. Email Address:

* 7. There is a $2,000.00 (USD) registration fee associated with all courses.  Will you or your organization be able to pay for this registration fee BEFORE the training program.