Registration Form for NASSPE Midwest Conference, October 14 2006
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| (Please complete form and PRINT it
out; details below) |
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| Name |
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| Street Address |
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| City, State, ZIP code |
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| Work Phone Number |
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| School District (if applicable) |
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| E-mail Address |
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| If using a credit card:
please specify Visa / MasterCard / American Express |
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| If using a credit card, please provide credit card number |
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| If using a credit card, please provide exp date |
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| If NOT using credit card, please indicate
method of payment (check, purchase order etc.) |
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| Number of attendees (if more than one, please also write the names of other attendees
in this space) |
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| Registration fee is $125 per person for one or two attendees;
$110 per person for 3, 4, or 5 attendees; and $100 per person for six or more attendees. |
Total registration fee |
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