Registration Form - January 12, 2001 Facilitators Conference

REGISTRATION FORM

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Midwest Facilitation Network
(http://www.midwest-facilitators.net)
25^th Midwest Facilitation Conference
Friday, January 12, 2001

Send to Registrar: E-Mail: pcollins@jordan-webb.net

Tel: (773) 463-2288

Fax: (773) 463-1830

                               Snail Mail:   MFN c/o Jordan-Webb
                                                  2656 West Montrose Ave - Suite 110
                                                  Chicago, IL 60618

25^th Midwest Facilitation Conference @ Summit Executive Centre - Downtown Chicago

_____________________________________ Conference Fee: $85/registrant: $ ____________
Company (on or before January 5th)

_____________________________________ Late Registration Fee: $95/registrant: $ ____________
^{Name

(after January 5th)}

_____________________________________ Walk-In Registration Fee: $100/registrant: $ ____________
Address & Mail Code (payment at the door)

_____________________________________ ___________-___________-___________-___________
City/State/Zip VISA / MASTERCARD NUMBER

_____________________________________ __________________________________ _____/_____
Business Phone Work Fax Signature Exp Date

_____________________________________ _____________________________________________
E-Mail Address and/or Website Address Your Company P O Number for Invoicing