IALEFI Master Instructor Development Program

Cortland, NEW YORK
September 12-14, 2011

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*:
$225.00 ________

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.)