Date: 

Last, First MI Email IVFA #

Students Home Address Apt. City

State Zip Home Tel# Work Tel# Ext Cell#

Billing Information

Authorized Billing Agent (FD/Organization/Unit)  

Authorized Billing Address 

City State Zip   Contact Person(ie. Accounts payable) Contact Tel:

If your organization is paying for this course, please list the person who authorized this payment  

Authorized contact Tel# Ext Payment Type Visa MasterCard Other Purchase Order   Purchase Order #                                                                                                                                                                                                                

Cancellation Policy:  All cancellations will be charged a $25.00 processing fee.  Last day to cancel is July 26, 2007 with the only penalty being the processing fee.  Any cancellations or "no shows" will be responsible for payment and/or no refund or credits will be issued after this date.  You may replace yourself with another student with no penalty.  You will receive a cancellation number, keep this for your records.  There is the possibility that classes may be canceled due to low enrollment.  It is recommended that you register as soon as possible once you are sure you will be able to attend.  Self paying students need to register with payment wither by Visa or MasterCard.  Departments may register with a P.O.#. 

 Please call in credit card numbers. Under construction 

NOTICE

If your first choice is not available please complete a second choice. If you would like to attend both courses that you list please note that in the comments box.  If there are more than two course that you would like to attend, please note that in the comment box as well, along with the course number, course name and dates.

 1st Choice Title:       Course #   Dates of Course

2nd Choice Title:    Course #    Dates of Course

YesNo

Comments:   

NOTICE TO ALL REGISTERED STUDENTS

By completing this registration you are responsible for payment and any cancellation fee that may apply.  You are also agreeing that the information completed is true and accurate.  If your department/organization or other entity  does not make payment  on or before the due date set forth on the invoice or by the IFIA, you will be responsible for payment.  Please make sure you are approved by your organization.  All information must be completed entirely on this registration form.  If you have any questions please feel free to contact the office.  800-235-0282 or email us at ifia@insightbb.com. 

I have read and understand the Cancellation Policy Must choose one Yes No

If this box is not checked, you need to contact the office before submitting the information.