Basic and Advanced WIDP Registration

WIDP Basic & Advanced Seminars Registration

* An asterisk indicates a required field.

CONTACT INFORMATION

First Name*

Last Name*

Title

Organization

Mailing Address*

Address (cont.)

City*

State/Province*

Zip/Postal Code*

Country*

Work Phone*

Home Phone

FAX

E-mail*

URL

PAYMENT INFORMATION

Payment option*

Credit Card Information
(Disregard if not paying with a credit card)

Name as it appears on your credit card

Expiration date (month/year)

Billing Address

Address (cont.)

Billing City

Billing State/Province

Billing Zip/Postal Code

Billing Country

CONFIRMATION

I am enrolling people in the WIDP . (Note: If you are enrolling anyone other than yourself, please note the names and addresses of the other attendees in the Comments section below.)

I understand that the fee of a seminar is $230 per person, or $130 for alumni. The fee includes a snack Friday evening and lunch Saturday. For anyone who does not already have a WIDP Profile, I understand I must also pay $40 to get my WIDP Profile.

By my signature below, I agree to allow Worley ID Profile to charge my credit card for the , unless I am paying by alternate means. (Note: If not paying with a credit card, please enclose a minimum deposit of $50 per person when you mail this form.)

PLEASE REVIEW THIS FORM CLOSELY FOR ERRORS BEFORE SIGNING.

Signature: ________________________ Date: _______

COMMENTS

Print, sign, date, and mail or fax this form to:

Worley's ID Profile
44 Farmers Row
Groton, MA 01450-1802
Tel: 978.448.2047
Fax: 978.448.3910

(For registration by credit card, you may opt to fax this form, rather than mailing it.)

NOTICE: WE RESERVE THE RIGHT TO CANCEL ANY SEMINAR IF THERE ARE NOT A SUFFICIENT NUMBER OF REGISTRANTS. IN SUCH CASES, A FULL REFUND WILL BE PROVIDED OF ALL DEPOSITS AND PAYMENTS FOR THE CANCELED SEMINAR.

After you have printed this form, click here for information regarding travel arrangements.

Be sure to visit our other site, www.coachexec.com!