PO Box 718 • Medina, WA 98039-0718
(800) 260-8180 • Fax: (425) 453-4103
www.iedseminars.org • register@iedseminars.org

Seminar Registration Form

Best Strategies for the Unique Needs of THIRD GRADE Students
MOUNTAIN, , March 31

Pricing Information

Standard Price: $279.00

Group Price: $259.00     Register 3 or more participiants for this seminar at the same time to receive discount.

Group registration?       List additional registrants on a copy of this form.

Personal Information
First Name: _________________     M.I. ___     Last Name: ______________________

Position: _________________________________      Grade Level ___________

Priority Code
Important! It is important that you fill in your Priority ID Code from your brochure, even if it was not addressed to you. It is the six digit number on the mail label next to the word "ID".
I have my brochure Priority ID Code: _____________
I don't have my brochure with me
I did not receive a brochure

Your School

School Name:     _________________________________________     School Phone:    ( _____ ) _____ – ________

School Address: _________________________________________     City/State/Zip:    _______________________

Home Address

Home Address: __________________________________________     City, State, Zip: ________________________

Home Phone:   ( ______ ) _______ – __________     E-mail Address: ______________________________________

Payment Information

Payment Method: Credit Card   Check   School or District P.O.   Bill Home   Bill School

Credit Card Information Visa  Mastercard  Discover

Cardholder's Name: _____________________________________________________

Card Number: ____________________________    CVV Number (on back of card) _______

Billing Zipcode: _____________    Expiration Date: ____ / ____

Purchase Order Payment

Purchase Order Number: _____________________________________