"SW Career Development Facilitator Certification"

REGISTRATION ( Please Print )

(One Registration per person, please!)

Name:_________________________________________ Date:______________

Work site:___________________________________ Position:______________

Mailing Address:_____________________________ Years experience:_________

                                            Number, Street Address

City, State, ZIP:_______________________________________________________

Telephone: (work)______________ (home)______________ (fax)______________

Email address:_______________________________________________________

Highest education completed:_____________________ Graduated?(Date)______

Will you wish CEU's for this training? _____yes _____no

I am registering for the program scheduled for: ______________________(date)

        Group Name:              _____________________________________________

        Fee Calculation:                             $1200.00 per person ($1100.00 Summer)

        Any discount applied:                   - ____________

                                        Total Due:     _____________

Check # or Purchase Order #:_____________________(PO from:_____________)

NOTE:

• Reservations require a down-payment of only $100 (non-refundable registration fee) applied to your total cost.
• Checks or Purchase Orders must accompany this registration.
• Mail Registration and payment or PO to:

Southwest CDF Training Center
c/o Action Associates
12231 Academy Rd. NE # 301-PMB258
Albuquerque, NM      87111

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