Regional Training Conference Registration Form
January 21- 22, 2008
Amarillo, TX
PLEASE PRINT CLEARLY
First Name: ______________________________________________ M.I. _______
Last Name: ______________________________________________ Suffix _____
(Jr., Sr., III, etc.)
Organization: ______________________________________________
Department: ______________________________________________
Work Address: ______________________________________________
City: _______________________ Province/State: _______________________
Postal Code: _______________________ Country: _______________________
Work Phone: _______________________ Home Phone: _______________________
Work Fax: _______________________ Toll Free #: _______________________
E-mail Address : _______________________

Home Address: ______________________________________________
City: _______________________ Province/State: _______________________
Postal Code: _______________________ Country: _______________________
Preferred Mailing Address (please check one):_____Work _____Home
Comments:
________________________________________________________________________________
________________________________________________________________________________
Method of payment:   ($75.00)
Card #______________________________________    Exp Date: __________________
Master Card  _____    VISA_____   American Express_____ Check/Money Order________  
Mail to:
IALEFI®
25 Country Club Road Suite 707
Gilford, NH  03249
Phone 603.524.8787

Fax:
603.524.8856