Yes! Please register me for SASEAP 2011! |
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| name | title |
address
| city | state | zip |
| phone (w) | phone (h) |
organization
I ___ will ___ will not be attending dinner on Friday night with ___ adults and cildren over 12 and ___ children 12 or under.
I will attending the ___ Basic EP Track ___ Advanced EP Track___ Clinic Track (check only one).
Workshop registration is $299.00 ($275.00 before August 16). You can pay by check or credit card. Send checks to the address below. Fill out the form below to pay by credit card and fax or mail the form to us.
| credit card number | expiration date |
name on card
billing address (if different from above)
| city | state | zip |
signature
You can fax this form to (919) 846-1431 (no cover sheet required), or mail it to: SASEAP, 8009 Shellnut Rd., Raleigh, NC 27615. (The fax is in a secure location, so your credit card information is safe.)