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Education Workshop Registration Form
Yes! I would like to attend the following workshop.
Please register me in the session and confirm the workshop's location.
Title: _____________________________________________________
Date: __________________________
Mailing Address:____________________________________________
__________________________________________________________
City: __________________________________ Zip: _______________
Telephone: _________________________ Fax: __________________
E-mail: ___________________________________________________
Fax to:
702-248-2771
or mail to:
Alzheimer's Association
Desert Southwest Chapter
5190 S Valley View Blvd, Suite 101
Las Vegas, NV 89118
Attn: Christine Buchmiller, Program Manager
Method of Payment: (if applicable)
____ Check Enclosed
____ Credit Card:
- ____ Visa
- ____ MasterCard
- ____ American Express
- ____ Discover
Credit Card #: _____________________________________________
Expiration date: ____________________________________________
Signature: _________________________________________________
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Contact Information:
Chris Terry
Program Manager
5190 S Valley View Blvd, Suite 101
Las Vegas, NV 89118
702-248-2770 p
702-248-2771 f
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