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Facilitator Workshop Charleston SC 01/09/2014

Authorized Facilitator Workshop Registration and Payment
* required information
  
 
Please complete the form below. Birth date is a required field for the prerequesite background check. If you are not working with an organization, select Independent as the Facilitator Affilitation.

Your registration will not be complete until you also submit your payment information on the next page.

Title:
Workshop Date:(mm/dd/yyyy)
First Name:*
Middle Initial:
Last Name:*
Birth Date:*(mm/dd/yyyy)
Phone:
Preferred Email:*
Organization Name:
Facilitator Affiliation:
Job Title:
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Country:*
How did you hear about us?:
Create Username and Password
Username:*
Password:*
Verify password:*
Security Question:*
Security Answer:*



Fees

Fees may include a registration late fee.
$350.00 Registration
Location: 7 Radcliffe Street, Suite 200, Charleston, SC 29403

Please proceed to the payment screen to complete your registration.