BSA Training Workshops Jacksonville, FL February 16, 2011 Credit Union___________________________________________________________ Mailing Address:_______________________________________________________ Contact Name & Phone Number:__________________________________________ Registrant Name: __________________________________Title:_________________ Email Address:_________________________________________________________ Morning Session _______
Afternoon Session _______
Registrant Name: __________________________________Title:_______________ Email Address:_______________________________________________________ Morning Session _______
Afternoon Session _______
Payment Information: Pay by check #__________ (Mail payment to: Attention Becki Payne, 22 Inverness Center Parkway Suite 200, Birmingham, AL 35242) CREDIT CARD AUTHORIZATION Credit Card Number
___ VISA
___ MasterCard Expiration Date
Cardholder’s Billing Address ______________________________________________________________________ City/State/Zip Print Name Authorized Signature CVV Number (three digit number found on back of card) * Please return completed registration form to Becki Payne @ fax # 205.991.2576