REGISTER BY FAX
Please complete this form, print it, and FAX it (if you're paying by credit card) to Lorrie Canciller at 919.962.3291.
Please call Lorrie at 919.962.0389 should you have questions about registration.
FIRST NAME:
LAST NAME:
BUSINESS NAME:
TITLE:
BUSINESS ADDRESS:
CITY:
STATE:
ZIP:
OFFICE PHONE:
E-MAIL ADDRESS:
Please use VISA or MasterCard only
It is mandatory that you complete the following credit card information if you want to register online for this event.
Card type: VISA MasterCard
Card #
Your card will be charged $150.
Expiration date:
Name (on card):
Typed signature:
(NOTE: Statement will list payment to "NCSU SBTDC INT")
