Note, there is an early bird registration discount ($525.00 per person).  Registration and payment must be received by March 15, 2012.  After that date, registration is $550.00 per person. 

Name: 
Department: 
Address: 
County:   
City:    State:    Zip: 
Dept. Phone: 
Home Phone: 
Your E-Mail: 

Additional participants name (only four participants total per department):
Name 2:    E-Mail: 
Name 3:    E-Mail: 
Name 4:    E-Mail: 

VISA, Mastercard, American Express Card#

Name on Card:   Exp. Date:

Or

Invoice to:

Department: 

Invoice E-Mail Address:

Billing Address: 

City, State, Zip: 

Department Contact: 

Telephone:      Fax: