Regional Training Conference Registration Form
June 12-13, 2008
Waunakee, Wisconsin
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________
$125.00_____ I am a current member    -or-    $180.00______I am not currently a member
Mail to:
IALEFI®
25 Country Club Road Suite 707
Gilford, NH  03249

Fax:
603.524.8856