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.

Questions? Please call us at 301 461 5065, or send us an e-mail.