EmailMe Form - Registration - Intelligent Influence

Please select a registration option: *

Single/Individual....$650 per person

Group/Multiple......$650 per person

Host Agency Group.......$550 per person

COVID-19 Lab Support Special........$220 per person

To qualify for the host agency discount, your agency must 1) have a minimum of 8 participants, 2) permit us to announce your hosting of this event, and 3) allow us to invite other students to participate. By selecting the Host Agency option, you acknowledge your agreement with these terms.

Please select a workshop date: *

If you selected Other above, please provide additional information:

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

Please enter the amount that we need to bill you.