ADAP Prevention Training

Essential Grant Skills

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Location: South Burlington, VT
Dates: May 25, 2010
Times: Registration & Refreshment: 8:00 – 8:30am
Training: 8:30am – 3:30pm
Cost: A $35 fee includes materials and a continental breakfast. Participants should bring a bag lunch.

IMPORTANT: Please include your name and the course title in the memo section of your check or purchase order. Thank you.

Please fill out the following information.

Participant Information:
Title	First name	Last name

Email Address

Email Address (again)

Organization or School Information:
Organization

School
(Pick 'none' if this doesn't apply.)
Other School

Other Supervisory Union

Street Address Line 1

Street Address Line 2 (Optional)

City

State	Zip

Work Phone Number

Work Fax Number

NOTE: So we can contact you in the event of cancellation, please provide your home phone number:
Home Phone Number (Please see note above)

Billing Information:
Purchase orders must be training specific; however, multiple registrants for the same training can be on the same purchase order.
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Billing Contact Name

Billing Organization

Street Address Line 1

Street Address Line 2 (Optional)

City

State	Zip

Phone Number

Fax Number

Personal Information:
Organizational Role

Other Organizational Role

Acedemic Credit

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