Seattle 2010 - 2011 Membership Registration
I am interested in:
Full Series
(Enter additional names below in Comments)
Membership
$1795
(Membership in the Summit series provides a 40% savings over individual course tuition prices.)
Name:
Clinic:
Street Address:
Mailing Address:
(if different)
City:
State:
Zip Code:
Email:
(for program reminder)
AGD #:
(Summit members only - we will submit your credits if you like)
Phone:
Fax:
Preferred Method of Payment:
(for credit card purchases, a Summit representative will contact you shortly.)
(select one)
Check
Bill Burkhart account
Credit Card
Comments:
(Include additional attendee names.)
