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: *

Confirm

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:

Registration Options: *

Early - By Credit Card - $220/student

Early - By Check - $220/student

Late - By Credit Card - $280/student

EARLY registrations must be paid prior to the start date of your program. LATE registration payments are accepted within 30 days after the start date of your program.

Instructions will be sent to the email address you provided in this form.

Amount Due:

$ Dollars . Cents

Please multiply the number of participants by the amount/student for your selected option