Registration Information (print this page for fax and
mail registration):
Name: ________________________________
Address: _________________________________________________
City:
________________________ State: _____
Zip: _________
Tel: (____) __________
Fax: (____) __________
E-mail: ________________________
Charge My: Visa
/ MC / Disc / Amex # __________________________
Exp Date:
_____________
Check enclosed, payable to:
The Supply Center
I acknowledge and agree that The Supply Center and the
respective locations in which the seminars are held assume no liability or
responsibility for any damage or loss that
might be incurred by me.
Signature (required): ____________________________________
DIRECTIONS:
(1) Print this form.
(2) Check the seminar date & location you want to attend.
(3) Mail or fax completed form with your check or payment information.
