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
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