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								Registration Form 
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						| If you are experiencing any technical 
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| First Name* |  | 
| Last Name* |  | 
| Position* |  | 
| Institution (No punctuation)* |  | 
| Department |  | 
| Address* |  | 
| City* |  | 
| State* |  | 
| Zip Code* |  | 
| Phone* |  | 
| Email* |  | 
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| How did you hear about the workshop? | 
| Email Colleagues
 Internet Search
 Conference I attended
 Other
 
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| Are you interested in learning more about an optional two-day in-person retreat (6/13-14) with an Alverno consultant? | 
| Yes, contact me regarding additional fees and options. 
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| Workshop Options* | 
| $1,100 (Individual Rate) $975 (per person Team Rate, 2 or more from same institution)
 
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| Payment Options* | 
| Check Credit Card
 Invoice My School
 
 Please include contact name, email, 
						invoice address, and PO # if needed
 
 
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