Microsoft Word - AMOTIA 1st Annual Conference, Registration Form.doc by ux10jsb


									                                          Registration Form
      Stalking Investigative and Intervention Strategies
                 A Victim-Centered Approach
          A one-day training sponsored by George Mason University Sexual Assault Services
                                    March 25, 2011, 8:30 am – 4:00 pm
                 George Mason University, 4400 University Drive, Fairfax, VA, 22030
                           Student Union Building II, Rooms 5, 6, and 7

    Name: __________________________________________________________________________

    Title: ___________________________________________________________________________

    Organization: ____________________________________________________________________

    Street Address: ____________________________________________________________________

    City: _____________________ State: ______________                  Zip Code: _____________

    Telephone: _________-_________-___________                 Fax: _________-_________-___________

    Email: __________________________________________________________________________

Registration fee includes training, light breakfast, coffee, lunch, and snacks.

    ____ $25 Non-George Mason University Organizations (check or cash)

    ____ $20 George Mason University Community Members (cash, check, or journal voucher)

    Do you require a parking pass? If so, it will be provided at the training.   ____ Yes

Registration form and full payment must be received by March 21, 2011.
Please make checks payable to George Mason University (Federal ID #54-0836354).
Send Completed Registration with Payment to:           Sexual Assault Services
                                                       MSN 2B2
                                                       George Mason University
                                                       4400 University Drive
                                                       Fairfax, VA 22030-4444
Directions will be sent in a confirmation e-mail upon receipt of your registration.
Six hours of DCJS Law Enforcement Career Development Credit is available.
For further information or an agenda, please contact Connie Kirkland (, 703-993-4364).
If you require special accommodations please contact George Mason University Sexual Assault Services at
703-993-4364 by March 21, 2011.

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