Registration Form for Workshop

REGISTRATION FOR WORKSHOP, OR EVENTS REQUIRING DEPOSITS

Name & Date of Event:
Your Title:
First Name:
Middle Initial:
Last Name:
Suffix:
Street Address:
City:
State:	ZIP:
Home Phone:
Business Phone:
E-mail:
Special needs:	First floor room Diabetic diet Vegetarian diet
Additional Comments:
The deposit for this event is indicated in the menu above, it is nonrefundable but applicable to cost of the event. You may use the secure connection of this page to pay the deposit by credit card below:
Kind of credit card:
Name & Address on card if different from above:

Credit Card Number:
Expiration Date (MM/YY):
AMOUNT: