1. Name:  

Organization:  

Address:   

City:   State:   Zip Code:   

Daytime Phone:  

Fax:  

E-mail address:  



2. Seminar and date for which you are registering:



3. Do you qualify for a discount as either a government employee or part of a group signing up together from the same company or organization?

Yes No

If yes:


a) What unit or agency of the state, federal or local government are you employed by?



b) Who are the others from your group who have registered or are registering for this event?




4. Registration Fee:


5. Method of Payment: