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