EmailMe Form - Registration - Intelligent Influence

Please select a workshop date: *

Who is this registration for? *

Only myself

Myself and other participants

Other participants, but not myself

Your Name: *

First Last

Agency or Employer: *

Your Title or Position: *

Contact Email: *

Phone: *

### - ### - ####

Agency Website/URL:

Mailing Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

How many total participants do you wish to include on this registration? *

If you are registering participants other than yourself, please write their full names AND email addresses below:

Method of Payment *

Credit Card Now

Credit Card Later

Check

Purchase Order (for groups of 3 or more only)

ATTENTION: If you are paying by check or need to pay by credit card at a later time, please close the PayPal payment page when you are directed to it. Your registration will still come to us.

Amount Due:

$ Dollars . Cents

Our workshop is $220 per participant, which includes a COVID budget relief discount. Please enter the amount due. You will have the option to pay online or submit a credit card form.