| Personal Information |
| Name: |
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| Nickname: |
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| Email Address: |
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| Home Phone: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Current Employer |
| Business Name: |
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| Business Phone: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Current position: |
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| How long have you held this position?: |
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| Year(s) of management or supervisory experience: |
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| Duties of present position: |
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| How many employees do you supervise? |
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| Education |
Highest
educational level attained:
12 College:
1
2
3
4
Graduate:
1
2
3
more |
| Undergraduate major: |
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| Graduate field: |
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| Program type: |
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| Seminar date you are enrolling for: |
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| What are your major
objectives in enrolling in this seminar? |
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| Referred by: |
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| Payment |
Payment information: You may pay by check. Please choose the appropriate option and follow the accompanying instructions.
Bill me personally
Bill my company
Installment/Deferment Form |
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| The fee includes all seminar materials, continental breakfast, lunch, and refreshment breaks. |
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| Bill me/Bill company: A bill will be sent either to your home address or your company's address provided above. Please call Kim Raap with any questions. |
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