INFO TANZA 2007

QUALIFIED MEMBER

REGISTRATION FORM

*Required Fields

*Name:*Phone Number

*Company Name:                    

*Address:                    

*City:                     *State Alabama Alaska Arizona Arkansas California Colorado District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Nova Scotia Ontario Prince Edward Island Quebec *Zip                    

*Email address                                                                                                                           

                                                         # Attending          

Thursday Firestone Certification Class                                            0 1 2 3 4 5 6 7 8 9 10

Friday, Information Seminars                                     0 1 2 3 4 5 6 7 8 9 10                                                

Saturday, Information Seminars                                     0 1 2 3 4 5 6 7 8 9 10   

Wet Lab

Meals will be  included (Breakfast, Lunch, and Dinner) at a cost of  $75.00 per day per person attending.  Drinks during the day will be provided.

Preferred Non-alcoholic drink  

Saturday Night Banquet                         0 1 2 3 4 5 6 7 8 9 10 x $15.00 Additional to daily meal cost

   I will attend the Annual Meeting Saturday

*Type of Card             Visa MasterCard American Express        *Total Amount to be Charged on Card           

*Credit card #

*Exp Date Month           January February March April May June July August September October November December   Year           2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

*Name on Card            

CVD #         

Same as Above

Billing Address

City:    State:  Alabama Alaska Arizona Arkansas California Colorado District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Nova Scotia Ontario Prince Edward Island Quebec   Zip: 

Comments:  If more than one attending, please list full names of the additional attendees.