IALEFI Master Instructor Development Program
Dallas, TEXAS - February 27-29, 2012

NAME_______________________________________________________________________________________________

AGENCY_____________________________________________________________________________________________

ADDRESS____________________________________________________________________________________________

CITY____________________________________________________________STATE________ZIP___________________

MAILING ADDRESS____________________________________________________________________________________

CITY____________________________________________________________STATE________ZIP___________________

CONTACT PHONE_________________________________________FAX________________________________________

E-MAIL ADDRESS_____________________________________________________________________________________

Agency Purchase Order ___________________________________

Credit Card Type r VISA r MasterCard r American Express r Discover
Account #_______________________________________________ Expiration Date ______ / ______
BILLING ADDRESS _____________________________________________ BILLING ZIP CODE __________
Security Code ______ Signature _______________________________________________________

REGISTRATION FEE*:
Member $225.00 ________
Non Member $280.00 (includes 1 years membership)_________________

Return to :
IALEFI
25 Country Club Rd, St 707,
Gilford NH 03249,

FAX 603-524-8856
Email: ljdavis@ialefi.com

(*Cancellation: Any cancellations after the registration has been processed will incur a 5% processing fee.)