Print this page out, fill it out and fax/mail it accordingly. Orlando Registration Form THE TRAUMA CONFERENCE - Exploitation & Sexual Trauma – A Special Focus on Cybersex Featured Speakers - Patrick Carnes, Ph.D. & John Bradshaw, Ph.D. I will attend: O Thursday, May 31, 2001 O Friday, June 1, 2001 O Saturday, June 2, 2001 O All Three Days A 10% Discount is Available for Groups of 3 or more registered together.. A 15% Discount is Available for full-time students (must include documentation of full-time student status). Only one kind of discount can be applied, discounts cannot be combined. NAME _________________________________________________________ COMPANY/AGENCY ______________________________________________ ADDRESS ______________________________________________________ CITY ________________________ STATE _____________ ZIP __________ DAYTIME PHONE NO. ___________________________________________ FAX PHONE NO. _______________________________________________ EMAIL ADDRESS _______________________________________________ ENCLOSE FULL TUITION Registration postmarked by April 19, 2001: THURSDAY FRIDAY SATURDAY ALL THREE DAYS $110.00 $110.00 $110.00 $299.00 Registration postmarked after April 19, 2001: THURSDAY FRIDAY SATURDAY ALL THREE DAYS $135.00 $135.00 $135.00 $345.00 METHOD OF PAYMENT O Check made payable to FACES O Purchase order attached O Charge my O Visa O Mastercard Register by Mail: FACES, c/o Richard Fields, Ph.D. 5010 243rd Ave. NE Redmond, WA 98053

Name of cardholder (Please Print) ___________________________________________ Credit Card Number _______________________________ EXP. DATE _____________ Signature _______________________________________________________________ Register by Phone: TOLL FREE 1-(877)63-FACES or (425) 868-7253 Register by Fax:(Confidential Line) (425) 868-5644 ---------------------------------------------------------------------------------------------------- Return to Previous Page