DFEB RegistrationPayment Information Sheet

1
DFEB Registration/Payment Information Sheet
For multiple attendees, attach list of attendees
names
ACTUAL PAYMENT MUST ACCOMPANY REGISTRATION(S).
Xeroxed copies of checks and registration form
will be accepted as proof that payment has been
mailed, but checks MUST be postmarked no later
than December 29, 2006.
All registrations are on a first-come,
first-serve basis, based on the time it is
stamped by the fax machine. Registration for
government employees begins November 17, 2006.
Registration will open to the general public on
December 4, 2006.

Name of Event ___________________________________
____________________________ Attendees Name
__________________________________________________
___________ Specify Any Special Needs
__________________________________________________
___ Agency ______________________________________
_______________________________
2007 MLK Diversity Training Seminar Featuring
Ms. Wilma Mankiller
(Dietary, Hearing Impaired, Handicapped, etc.)
Date Processed ___________________________
Batch _________________________
Payment Information
Payment by (Circle One) Cash Check
Credit Card Visa or Master
Card Credit Card Number ________________________
____________________________________ Expiration
Date ____________________
Verification Code _____________________ Name as
it Appears on the Card___________________________
_________________________ Cardholders Phone
FAX ____________________________________________
___________ Cardholders Email
__________________________________________________
____________ Credit Card Billing Address Zip
Code ____________________________________________
__ _______________________________________________
_______________________________ Cardholders
Signature _______________________________________
____________________
(This code is the last 3 digits on the back of
the card by the signature)
(Actual POB or address where credit card bill is
sent )
Charge Calculations
Deadline for Registration January 11,
2007 Seating is limited! Reservations are
first-come, first-serve.
Cost of Event (per person)
_____________ X Number of Attendees
_____________ Total
Authorized CC Charge _____________
99.00
Fax or mail registration/ payment information to
Irene Wise MLK Registrations USDA/FNS 1244 Speer
Blvd, Suite 903 Denver, CO 80204 Phone
303-844-0379 FAX [phone] Email
irene.wise_at_fns.usda.gov