ACTE Regional Summit

Registration Form

All fields are required unless marked with a "*". Name, Title and Company will appear on badge as submitted.
Last Name, First Name
Title
Company/Affiliation
Address
Address*
City
State/Province*
Zip/Postal Code
Country
Telephone
Facsimile*
E-Mail
Registration Fee:	Member $40 CAD Non-Member $58 CAD (Fees include lunch)
Payment:	Check American Express Diners Club MasterCard Visa
Cardholder Name
Card Number
Expiration Date
(Note: To pay by check, please do not submit this form on-line. Instead use your browser's print feature to print the completed form, make written note that a check has been mailed, and fax it to 1-703-683-2720. You should also print this form if you require a receipt of registration.) You may submit this form online by Fax: 1-703-683-2720 or Mail: ACTE Powertalks, 515 King Street, Suite 340, Alexandria, VA 22314. You may call 1-703-683-5322 or 1-800-ACTE-NOW for questions or more information. (REFUNDS ONLY GIVEN ONE WEEK PRIOR TO FORUM.)