Registration Form - April 27, 2001 Facilitators Conference

REGISTRATION FORM

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Midwest Facilitation Network
(http://www.midwest-facilitators.net)
28^th Midwest Facilitation Conference
Friday, January 18, 2002

Send to Registrar: E-Mail: register@midwest-facilitators.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

28^th Midwest Facilitation Conference @ Stuart School of Business (Downtown Chicago) - January 18, 2002

_____________________________________ Discounted Early Registration Fee: $100/participant: $ ____________
^{Name
(if registration received on or before January 11, 2002)}

_____________________________________ Conference Registgration Fee: $120/participant: $ ____________
^{Company
(if registration received after January 11, 2002)}

_____________________________________ Walk-In Registration Fee: $120/participant: $ ____________
Address & Mail Code (if payment received at the door)

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

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

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