Print this page out, fill it out and fax/mail it accordingly. Portland Registration Form SCHOLARSHIPS - Partial Scholarships are Available for Professionals Working in Non-Profit Agencies. For qualification information contact Deborah Jerome, Scholarship Coordinator. CALL TOLL FREE 1-877-63FACES I will attend: O Wednesday, April 4, 2001 O Thursday, April 5, 2001 O Friday, April 6, 2001 O All Three Days NAME _________________________________________________________ COMPANY/AGENCY ______________________________________________ ADDRESS ______________________________________________________ CITY ________________________ STATE _____________ ZIP __________ DAYTIME PHONE NO. ___________________________________________ FAX PHONE NO. _______________________________________________ ENCLOSE FULL TUITION 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 can not be combined. Registration postmarked by February 28, 2001: WEDNESDAY THURSDAY FRIDAY ALL THREE DAYS $110.00 $110.00 $110.00 $299.00 Registration postmarked after February 28, 2001: WEDNESDAY THURSDAY FRIDAY ALL THREE DAYS $130.00 $130.00 $130.00 $349.00 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 Register by Fax: (425) 868-5644 ---------------------------------------------------------------------------------------------------- Return to Previous Page