Developing Leaders To Make A Difference™
 
 

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Print this page, fill it in and mail it in with your payment.

Business/Organization: _______________________________________________________________________________

Street: _________________________________City: ______________________________State: ______ Zip: _________

Day Phone: _______ - _______ - _______________ FAX Phone: _______ - _______ - _______________

Email Address: _________________________________________________ (e.g. johndoe@mail.com)

    Price Subtotal
First Registrant First Name: _____________________ Last name: _______________________ $69 $69
Second Registrant First Name: _____________________ Last name: _______________________ $59 $138
Third Registrant First Name: _____________________ Last name: _______________________ $49 $187
Forth Registrant First Name: _____________________ Last name: _______________________ $49 $236
Fifth Registrant First Name: _____________________ Last name: _______________________ $49 $285
Sixth Registrant First Name: _____________________ Last name: _______________________ $49 $334

If additional lines are needed, simply type them up on the back of this form and add the appropriate amount to the total.

Comments

Mail to:

Bethany Church
Attn: MI2005
763 N. Sunset Ave.
West Covina, CA 91790

A Confirmation letter will be sent to you. Cut off date for mail in registration is postmarked by April 15, 2004.
 

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