Name:

  Business:

  Street Address:

  City:

  State:

  Zip code:

  Phone number:

  Fax number:

  E-mail address:

  Type in date and location of seminar: 

   (Example: 01-04-2000, Albion, MI)            

  Number attending:

  Choose one of our easy payment methods. Or call 260-495-1732

  Choose Payment Method:  

        
  Visa/Master card    
       (If paying by credit card, registrar will call for card number)

     
  Purchase Order:  
        (If paying with purchase order, we will issue invoice) 

    
  Check:

        (if paying by check) Make Payable to:

  Industrial Opportunities
  P.O. Box 12541
  Ft. Wayne, IN 46863