Washington Seminar, 2008

The Synergetic Connection

April 17 and 18, Thursday and Friday, 9:00am to 8:00pm

Registration Form

Print and mail with seminar fees to: Seminar '08, c/o Kitty Trescott, 1214 W. Schwartz, Carbondale IL 62901.

• Name: _______________________________________________
  
  
• Email: _______________________________________________
  
  
• Mailing address: _______________________________________
  
  
• City: ________________________________________________
  
  
• State: ______________________________________
  
  
• Zip: ________________________________________
  
  
• Chapter or Region: ____________________________
  
  
• Phone: ______________________________________
  
  
• For the visit with the U.S. State Department, please provide the following information:
  
  
• (US Citizen) Driver's license #: __________________________ Bate of Birth: ____________________________________
  
  
• State of issue: ______________________________
  
  
• (Non-US Citizen) Passport #: ______________________________
  
  
• Country of citizenship: ____________________________________
  
  

Remember to register with the hotel also.
Direct all inquiries and or questions to: Kitty Trescott by email or call 618.549.1555
Return to registration information and schedule.