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Sign me up for a workshop!

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  • 6 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

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Sign me up for a workshop!
Just fill out this registration form. Please complete a separate form for each person registering.
Name _____________________________________________________________________________________
Licensed Profession and License # ______________________________________________________________
(required to receive continuing education credits for LMSW, LCSW, MFT & MHC)
Home Address ______________________________________________________________________________
Home Phone ________________________________ Email ___________________________________
Employer __________________________________ Employer’s Phone _________________________________
Employer’s Address __________________________________________________________________________
Total Amount Enclosed $ ___________ Check enclosed payable to Tompkins Cortland Community College
MasterCard Visa Discover Company Invoice
Cardholder’s Name _____________________________________________________________________________
Card Number ___________________________________________ Expiration Date ______________________
Signature ______________________________________________ CVV2 number ________________________
I certify that the information on this application was provided voluntarily and is accurate to the best of my
knowledge.
Course Title _____________________________________ Fee $ _______
Course Title _____________________________________ Fee $ _______
Course Title _____________________________________ Fee $ _______
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Phone
Register by phone with MasterCard, Discover or Visa to reserve your seat in the workshop(s) of
your choice. You will receive your registration confirmation once your registration/payment
has been processed. Please have all the information requested on the mail-in form when
calling.
Mail
Complete the registration form and send to:
BIZ, PO Box 139, 170 North St, Dryden, NY 13053
Fax 607.844.6535
Register by fax with MasterCard, Discover, Visa or purchase order number using the mail-in
form.
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Sign me up for a workshop

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Completed 26 July 2020

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