Rapid Eye Check Workshop Registration Form

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Rapid Eye Check Workshop Registration Form

Date: March 17, 2004
Time: 9:00 am - 1:00 pm
Location: 1606 W. Indian School Road
Cost:
$150.00 (member)
$215.00 (nonmember)
$180.00 (AGC/Government)
(Additional attendees from the same company will receive $25.00 discount per person).

Name:

Organization:

Contact Person:

Address:

City, State, Zip:

Phone:

E-mail:sp;

Fax:;

PAYMENT

Payment Enclosed for $_____________________________

Invoice My Company (Purchase Order#)________________

Visa/Master Card Credit Card Number:________________

Expiration Date:____________________________________

Signature on Card:__________________________________

Register by MAIL: 1606 W. Indian School Rd, Phoenix, 85015
Register by FAX: (602) 277-5485
Register by PHONE: (602) 234-1698, ext. 1

Advance registration is required. Seating is limited.
There will be a 25% charge for "no-shows".
Only Cancellations (3) business days' prior will be refunded in full.

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Name:
Organization:
Contact Person:
Address:
City, State, Zip:
Phone:
E-mail:sp;
Fax:;