fall conference regform

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					Fall Conference Registration                                       (suggested by September 14, 2012)
(Please register each person; make copies as needed. Information will be kept confidential.)
Name:
Agency:
Address:
City:                                 St.:            ZIP:
Telephone:
E-mail (for receipt confirmation and credit-card registrations):


Please check all that apply.
  __ Participants (full day, both sessions) ...................... $100
  __ Participants (morning only) ................................... . $50
  __ Participants (afternoon only) ................................. . $50
  __ Lunch ................................................................... $10
  __ Parking hangtag ...................................................... $5
  __ Students ................................................................. $5
  __ Continuing Education Units: __0.3 or __0.6 ............ $10
  __ FREE contact hours: __3 or __ 6
  __ Discount for MUAA members or field instructors:
    $10/session ................................................... -$10/$20
        TOTAL: .............................................................. $___
  __ Check or money order
     (payable to the University of Missouri)
  __ Credit card
        Card type: __MC __Visa __Discover
Card no.:
Expir. date:                         E-mail:
Name of card holder:
Billing address and ZIP Code of card holder:




Send to:
Deborah Simmons
MU School of Social Work
729 Clark Hall
Columbia, MO 65211-4470
573/882-4447
FAX 573-882-8926

Registrations paid by credit card may be e-mailed to: ssw@missouri.edu

				
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posted:9/17/2012
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