Program # 2610120
January 27-29, 2000   •   Turnbull Conference Center   •   Tallahassee, Florida
Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

SSN_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Affiliation_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ _

Address (indicate if home or office)_ _ _ _ _ _ _ _ _ _ _ ______ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

City _  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  State_ _ _ _ _   Zip_ _ _ __ _ _ _ _ _

Daytime phone _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _    Evening phone_ _ _ _ _ _ __ _ _ _ _ _ 

E-mail_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _    Fax_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 
I have enclosed payment for the following:
     Through 12/1/1999                                             After 12/1/1999
   o Participant fee $95                                       o Participant fee  $ 110
   o Non-presenting participant fee $75                 o Non-presenting participant fee $85

My preferred method of payment is:
   o Check (payable to Florida State University in US currency)
   o Purchase Order (attach copy)
   o Charge           o MasterCard          o Visa          o American Express

Account # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Exp. Date_ _ _ _ _ _ _ _

Signature_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

COMPLETE this form, enclose your payment and register one of these 4 easy ways:

Register today!
Call
(850) 644-3806
8:30 am-5:00 pm
Mail
registration to
CPD/FSU 
Tallahassee, FL 32306-1640
Fax
registration to 
(850) 644-3803 
Open 24 hours
E-Mail
registration info to
skormondy@cpd.fsu.edu
     Should you require it, our FEID# is 591961248. If you have a disability requiring accommodation, please call (850) 644-2118 at least seven days prior to the program.
For additional information about this program, please call Sheryl Kormondy at (850) 644-2118.