Registration Form - October 21, 2002 Facilitators Conference (30th)

REGISTRATION FORM

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Midwest Facilitation Network
(http://www.midwest-facilitators.net)
31st Midwest Facilitation Conference
Friday, January 10, 2003

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

31st Midwest Facilitation Conference @ Summit Executive Centre
Downtown Chicago, Illinois - Friday, January 10, 2003

_____________________________________ Discounted Early Registration Fee: $100/participant: $ ____________
^{Name

(if registration received on or before January 6, 2003)}

_____________________________________ Conference Registgration Fee: $120/participant: $ ____________
^{Company
(if registration received after January 6, 2003)}

_____________________________________ 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