Regional Training Conference Registration Form
September 22 - 24, 2003
Des Moines, Iowa
PLEASE PRINT CLEARLY
First Name: ______________________________________________ M.I. _______
Last Name: ______________________________________________ Suffix _____
(Jr., Sr., III, etc.)
Organization: ___________________________________________________________________________________
Department: ___________________________________________________________________________________
Work Address: ___________________________________________________________________________________
City: _______________________ Province/State: ___________________
Zip Code: _______________________

Work Phone: _______________________ Home Phone: _______________________
Work Fax: _______________________ Toll Free #: _______________________
E-mail Address : ____________________________________

Home Address: ____________________________________________________________________________________
City: _______________________ Province/State: _______________________
Zip Code: _______________________

Preferred Mailing Address (please check one):_____Work _____Home
Comments:
________________________________________________________________________________
________________________________________________________________________________
Method of payment:
Card #______________________________________    Exp Date: __________________
Master Card  _____    VISA_____   American Express_____ Check/Money Order________
$150.00_____ I am a current member    -or-    $200.00______I am not currently a member

After Sept. 5, 2003
$175.00_____ I am a current member    -or-    $225.00______I am not currently a member
Mail to:
IALEFI®
25 Country Club Road Suite 707
Gilford, NH  03249
603.524.8787

Fax:
603.524.8856