| Employment Information |
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| Your Name: |
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| Title/Position: |
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| School District: |
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| School Name: |
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| School Address Line: |
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| City: |
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| State: |
Zip Code:
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| Office Phone & Ext: |
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| Office Fax: |
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| Email Address (Required): |
(Required) |
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| Personal Information |
This Information is Required for ACT48 Reporting: |
| Address Line: |
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| City: |
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| State: |
Zip Code:
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| Home Phone: |
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| Social Security # |
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| Registration Selection |
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Differentiated Supervision; April 20, 2004 -
Capitol Area Intermediate Unit #15, Summerdale: 9:00-12:00 pm, Lunch
12:00-1:00 pm |
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Member Rate, $65 |
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Non-Member Rate, $140 |
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Teambuilding; April 20, 2004 - Capitol Area
Intermediate Unit #15, Summerdale: 1:00-4:00 pm, Lunch 12:00-1:00 pm |
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Member Rate, $65 |
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Non-Member Rate, $140 |
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Both Seminars! |
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Member Rate, $120 |
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Non-Member Rate, $180 |
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| Lunch |
Do you intend to stay for lunch (included in price)?
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Yes, I plan on staying for lunch. |
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No, I do not plan on staying for lunch. |
| Please Enter Purchase Order Information (If
Already Available) |
P.O. #:
Date:
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