TRAINING SEMINAR DELEGATE REGISTRATION FORM        Print Form
(fill out and fax to (865) 908-7104)

Workshop You're Registering For:
_________________________________ (example: Savannah Leadership)

Organization/Artist Name: ________________________________________________

Principal Contact: _________________________________   Phone: _______________

Address: ____________________  City: ______________ State:_______ Zip:_________

Fax: _______________ Email: ______________________    www.__________________
 

(Mark all that apply below)

	H-Hypnotist
	MG-Magic/Mentalist
	C-Comedy
	D-Diversity
	L-Lecture
	M-Music
	PR-Products/Services
	N-Novelty/Variety
	P-Poetry/Spoken Word
	T-Theatre/Performing Arts
Select Package:
	Bronze Package $1,995
	Gold Package $2,995
	Platinum Package $3,995

Delgate application section:

Name: ___________________________ Special Meal: ___ Kosher ___Veg.  ___ Vegan

Name: ___________________________ Special Meal: ___ Kosher ___Veg.  ___ Vegan

Name: ___________________________ Special Meal: ___ Kosher ___Veg.  ___ Vegan

Total Number of Delegates: ________ Total to be charged to card: $_________ (to be setup on monthly billing please call Amy at APCA at 1-800-681-5031)

Credit Card Orders: VISA____ MC _____ AmExp____  Number:___________________ Ex: ____/_____ Name on Card ________________________ Signature _________________ Date: ____/____/ ______ Billing Address: ________________________________________  CVV2#: _____________

Signature of Firm Representative: ___________________________ Print Name: ____________________________  Date: ___________________