Regional Training Conference Registration Form
April 2 - 4, 2003

Santa Ana Tribal Police Department
Pueblo of Santa Ana (Bernalillo) New Mexico


 
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:
Card #______________________________________    Exp Date: __________________
Master Card  _____    VISA_____   American Express_____ Check/Money Order/PO________
before March 14:  $150.00_____ I am a current member    -or-    $200.00______I am not currently a member
after March 14:     $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

Fax:
603.524.8856