Print this page out, fill it out and fax/mail it accordingly.

Seattle Registration Form

I will attend: O Wednesday, February 27, 2002 O Thursday, February 28, 2002
O Friday, March 1, 2002 O All 3 days of the conference

NAME _________________________________________________________

ORGANIZATION _______________________________________________

ADDRESS ______________________________________________________

CITY ________________________ STATE _____________ ZIP __________

DAYTIME PHONE NO. ___________________________________________

FAX NUMBER _________________________________________________

EMAIL ADDRESS*: _________________________________________________

ENCLOSE FULL TUITION

*Registration confirmations and directions to the hotel will be emailed to you upon receipt of your registration payment. If you don't have an email address, they will be faxed or mailed.

A 10% discount is available for groups of 3 or more registered at the same time. 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:
NOVEMBER 20, 2001
WED. ONLY
THURSDAY ONLY
FRIDAY ONLY
ALL 3 DAYS
 		$110.00
$110.00
$110.00
$299.00
REGISTRATION POSTMARKED BY:
DECEMBER 20, 2001
WED. ONLY
THURSDAY ONLY
FRIDAY ONLY
ALL THREE DAYS
 		$135.00
$135.00
$135.00
$345.00
REGISTRATION POSTMARKED AFTER:
DECEMBER 20, 2001
WED. ONLY
THURSDAY ONLY
FRIDAY ONLY
ALL 3 DAYS
 		$145.00
$145.00
$145.00
$375.00
  • ORDER your copy of The Gift of Therapy $26.95

    • METHOD OF PAYMENT
    O A check made payable to FACES
    O Purchase order is 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 Clearly) ___________________________________________

    CREDIT CARD # (Please Print Clearly)_______________________________ EXP. DATE ____/____

    SIGNATURE ______________________________________________________________

    Register by Phone:
    (877) 63-FACES
    (425) 868-7253         		Register by Fax:
    (425) 868-5644
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