THIS IS NOT AN ONLINE REGISTRATION FORM - FOR PRINT ONLY            Printed Date: 6/20/2019 5:18:57 PM

Seminar Title:
Dyslexia: Building NEW Neuropathways to Master Visual and Auditory Memory, Visual Perceptual Skills, Visual Motor Skill Development & More!
Seminar Date:
Thursday, June 13, 2019
Seminar Location:
COLUMBIA, MD 21044
Seminar ID:
71258

  Required (select one)
 
$229.99 Single Registration
$199.99 2+ Group Rate: per person
$189.99 5+ Group Rate: per person
$115.00 Student
  ________ HI, NM attendees add applicable sales and local taxes**
  ________ Subtotal (Required items + sales tax)
 
  Optional
 
$26.99 Fun with Literacy: 100s of Activities, Exercises and Tips for The Classroom & Therapy (Birth-Preschool)
$24.99 Social and Emotional Development in Early Intervention
$19.99 Yoga and Mindfulness Practices for Children Card Deck
  ________ AL, AR, AZ, CA, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NJ,
NM, NV, NY, OH, OK, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY attendees add applicable sales and local taxes**
  ________ Subtotal (Magazines + Optional items + sales tax)
   
  ________ Total (Required subtotal + Optional subtotal)
  ** Tax-exempt customers please send a copy of your tax-exempt certificate.
  *** Registration for coordinator or military member discount must be completed online or by calling (800) 844-8260 during business hours.
  **** All prices are shown in US Dollars ****
 
 

Please enter the MAIL CODE in the box below.

If you have a brochure, this code is found on the
back in the box above the address block.

If you do not have a brochure, please enter 888.

Mailcode Example
Mail Code or VIP #:
*  
First Name:
*     Last Name: *
Profession:
*
  Note: Leave Company/Department blank if providing home address
Company Name:
*
Department:
*
Address:
*
City:
*    State: *    Zip: *    County: *
Work Phone:
*      Cell Phone:   *      Fax Number:  
Email Address:
*    License Number: *
(required for confirmation of registration)

  Prepayment is REQUIRED
  Check enclosed
  Signed Purchase Order enclosed
Credit Card Type:
Mastercard    Visa    Amex    Discover
Credit Card #:
  V-Code #*
Exp Date:
/ *MC/Visa/Discover: last 3-digit # on signature panel on back of card
*American Express: 4-digit # above account # on face of card
Name on Card:
Mail or Fax to:
PESI Kids, P.O. Box 1000, Eau Claire, WI 54702-1000      (800) 554-9775 (fax number)