Registration for Workshops
NAME
*
LICENSE TYPE
*
ADDRESS
*
CITY, STATE, ZIP
*
HOME PHONE
*
WORK PHONE
*
EMAIL ADDRESS
*
DATE OF WORKSHOP YOU WISH TO ATTEND
*
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
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30
31
LOCATION OF WORKSHOP
*
WILL YOU PAY BY CHECK?
*
Yes
No
WILL YOU PAY BY CREDIT CARD?
*
Yes
No
TYPE OF CREDIT CARD(MC, VISA, etc.)
CREDIT CARD NUMBER
EXPIRATION DATE ON CARD
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
NAME and BILLING ADDRESS OF CREDIT CARD
Credit Card Security Code
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Copyright 2008, Steven Vazquez, PhD
