Registration Form - January 24, 2005 - 36th Midwest Facilitators Conference

REGISTRATION FORM

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Midwest Facilitation Network
(http://www.midwest-facilitators.net)
36th Midwest Facilitation Conference
Monday, January 24, 2005

Send to Registrar: E-Mail: 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

36th Midwest Facilitators' @ Summit Executive Centre
Downtown Chicago, Illinois - Monday, January 24, 2005

________________________________________
^Name

Discounted Early Registration Fee: $110.00/participant:
^{(if registration
received on or before January 18, 2005)}

$______

________________________________________
^Company

Conference Registgration Fee: $125.00/participant:
^{(if registration
received after January 18, 2005)}

$______

________________________________________
^{Address & Mail Code}

Walk-In Registration Fee: $135.00/participant:
(if payment received at the door)

$______

________________________________________
^{City/State/Zip}

_________-_________-_________-_________
Visa-MasterCard-American Express-Discover-Diner's Club

________________________________________
^{Business Telephone} ^Business^Fax
_______________________    _________   _______
Signature                                 Exp Date         VCODE

____________________________________
E-Mail Address                                      Website

___________________________________
Your Company Purchase Order # for Billing

Mark Tandem Session Choices:    Session 2: A - B

    /    Session 3: A - B

________________________________________ ^Name	Discounted Early Registration Fee: $110.00/participant: ^{(if registration received on or before January 18, 2005)}	$______
________________________________________ ^Company	Conference Registgration Fee: $125.00/participant: ^{(if registration received after January 18, 2005)}	$______
________________________________________ ^{Address & Mail Code}	Walk-In Registration Fee: $135.00/participant: (if payment received at the door)	$______
________________________________________ ^{City/State/Zip}	_________-_________-_________-_________ Visa-MasterCard-American Express-Discover-Diner's Club
________________________________________ ^{Business Telephone} ^Business^Fax	_______________________ _________ _______ Signature Exp Date VCODE
____________________________________ E-Mail Address Website	___________________________________ Your Company Purchase Order # for Billing

Mark Tandem Session Choices: Session 2: A - B	/ Session 3: A - B