REGISTRATION FORM - MIDWEST FACILITATORS' NETWORK ------------------------------------------------- http://www.midwest-facilitators.net 28th Midwest Facilitators' Conference ------------------------------------- Friday, January 18, 2002 Stuart School of Business (Downtown Chicago) Email: E-mailto:register@midwest-facilitators.net Tel: (773)-463-2288 Fax: (773)-463-1830 Snail Mail: MFN c/o Jordan-Webb 2656 West Montrose Ave - Suite 110 Chicago, IL 60618 28th Midwest Facilitators' Conference ------------------------------------- Friday, January 18, 2002 Stuart School of Business (Downtown Chicago) Early Registration Discount Fee: $100/participant: $ ____________ (if registration received on or before January 11, 2002) Conference Registration Fee: $120/participant: $ ____________ (if registration received after January 11, 2002) Walk-In Registration Fee: $120/participant: $ ____________ (if payment received at the door) ________________________________________________________ Name ________________________________________________________ Company ________________________________________________________ Address & Mail Code ________________________________________________________ City/State/Zip ________________________________________________________ Business Phone Business Fax ________________________________________________________ E-Mail Address and Website Address ________________________________________________________ Your Company P O Number for Invoicing ___________-___________-___________-___________ ______/______ VISA / MASTERCARD Number Card Exp Date ________________________________________________________ Signature