Seafood HACCP Alliance

Basic/SCP

Student Information Sheet

Course Number

First Name	Internet Segment-Two Student (check)

MI

Last Name

Company

Address 1	I	I

Address 2

City	State	Zip

Country

Phone Ext. Fax

Email

Training Location:City	Training Location:State

Training Date

Professional Affiliation: Please circle one

Industry	Government	Education	Consultant	Other

AFDO Region: Please circle one
AFDOSS CASA	MCA	NCAFDO	NEFDOA	WAFDO