Registration Form for NASSPE Midwest Conference, October 14 2006
(Please complete form and PRINT it
out; details below)
Name
Street Address
City, State, ZIP code
Work Phone Number
School District (if applicable)
E-mail Address
If using a credit card:
please specify Visa / MasterCard / American Express
If using a credit card, please provide credit card number
If using a credit card, please provide exp date
If NOT using credit card, please indicate
method of payment (check, purchase order etc.)
Number of attendees (if more than one, please also write the names of other attendees
in this space)
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
Please print out this form, then either FAX it to NASSPE at 301 972 8006, or MAIL it to NASSPE at 19710 Fisher Avenue, SUITE J, Poolesville,
Maryland, 20837.