Event or Course Name:                   

      Alternate Course Name:                  

      (Please list an alternate course you would take, if your first choice is not available, or enter None.)

Amount authorized:                               

Name of person registering:                  

Your email address:                      

Your phone number:                    

Name of cardholder as printed on credit card:                      

Credit Card Number:                                                     Visa or Master Card only.

             Please re-enter for validation purposes:                  

Credit Card Expiration Date:                                               

Note: Your Credit Card will not be charged until we have verified that the course will be conducted.  This form also serves as your registration.

Billing Address for the Credit Card:

 Street:                                                             

 City:                                                                

 State:                                                              

 Zip:                                                                 

Please print out copy for your records before submitting.

NOTE: You may receive a FrontPage Error screen after submitting.  This is for security purposes.  You should receive a separate email message to confirm that your charge form has been received and when the charge will be processed. 

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