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SEMINAR REGISTRATION FORM
INTEGRITY ASSURANCE
Title Click Here Ms Miss Mrs. Mr. Rev. Dr. Name Address City State Please Select AL AK AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NJ NH NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY CANADA OVERSEAS Zip/Postal Code MDS Student ID# Your Current Degree Level Select Your Current Degree Level. Certificate Program Associate Degree Bachelor's Degree Master's Degree Doctorate Degree E-mail Address Best Telephone (probably your cell phone) Alternative Telephone
I am Registering for the following Seminar to be held on the date I have indicated:
First Seminar Date of the Seminar
Second Seminar Date of the Seminar
Third Seminar Date of the Seminar
More than three seminars: If you wish to register for more than three seminars, please call 1-800-933-1445 and ask to speak with Mrs. Jean Trotter, or email her jtrotter@mdivs.edu.
SELECT YOUR ATTENDANCE STATUS & PAYMENT AMOUNTS
REGISTER FOR A DVD SEMINAR There is no registration fee for a DVD seminar, so I am paying the full seminar amount as noted below. Please Select Your Status. I am a current student at Master's I am a graduate of Master's. I am not a student or graduate.
ATTEND ON-SITE FOR C.E.U. CREDIT ONLY At this time, I am paying a $40.00 Pre-Registration C.E.U. Fee for each of the Seminars I have indicated above. The total amount of my Pre-Registration Fee(s) ($40.00 per-Seminar) is: Select $40 (one Seminar) $80 (two Seminars) $120 (three Seminars) Please Select Your Status. I am a current student at Master's I am a graduate of Master's. I am not a student or graduate.
-Payment of the Full Seminar Fee-
In addition to paying the Pre-Registration Fee (if any) for each of the Seminars I have indicated above, I am paying the remaining Seminar Fee at this time. The total amount I am paying is:
-Payment Alternative for On-site Seminars Only-
I AM NOT PAYING the rest of the Seminar Fee at this time, but I do realize I MUST PAY the final balance not later than two weeks prior to the Seminar (unless other arrangements have been approved), and that the Pre-registration Fee is not refundable, though it may be applied toward another seminar in the event that I must cancel. However, the actual Seminar Fee is refundable in the event I am not able to attend.
-Complete Your Payment Method-
Total Amount I am Paying at This Time Including Pre-Registration (if required) and Seminar Fees: I am paying by credit or debit card (we accept only Discover, MasterCard or Visa).
Please select the type of card to use now, and then complete the rest of the information. Or, if you prefer to give your credit card by telephone rather than online, select your preference: Select your card type or preference. --- Use my Visa Card with number, expiration and name as noted below. Use my MasterCard with number, expiration and name as noted below. Use my Discover Card with number, expiration and name as noted below. --- I prefer to give my card number by phone. Please call me. Card number: Expiration Date: Exact Name on card:
Alternative Payment Method: If you wish to register using a payment method other than a credit or debit card, please call 1-800-933-1445 and ask to speak with Mrs. Jean Trotter, or email her jtrotter@mdivs.edu.
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