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On Address State AL City Zip Code Phone Number Fax Number SS# (last 4 digits) Birth Date MM/DD/YYYY (for CEUs/transcript purposes only) Email The information on this form is private data, used to identify and locate you. Name, address, and payment method are mandatory. Registration Rate: Registration fees include workshop materials, continental breakfasts, lunch (Tuesday only) and convenient and free parking. $129.00 Early Bird (before June 1, 2010) $149.00 (after June 1, 2010) Payme.

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