IMTEC Corporation

The fields with a '*' are mandatory. We will need either a phone number or an e-mail address to inform you of any changes as well as to contact you for confirmation of your selected dates and locations.

MDI - 1 Day Mini Residency
Course Information for 2008

Date and Location of courses interested in *

Company Name

Personal Information / Billing Address

First Name*

Middle Initial

Last Name*

Title*

Address*

City*

State

Zip

Country *

AGD Member No.

(6 digit member number is not require but recommended)

Daytime Phone *		Fax		E-Mail Address *
(We may contact you via phone to confirm this application)				(We may contact you via e-mail to confirm this application)

Payment by Credit Card

Credit Card Information. We gladly accept the following credit cards

Credit Card Type*

Card Number*

Exp. Date*

Comments/Discount Code

			I agree to these terms and I understand that I will be billed for $985.00 (US)
	*

Payment by Check

Should you decide to pay for your tuition by check you may download a version of this form and mail it in with your check to:

CORPORATE OFFICE
2401 North Commerce
Ardmore, OK 73401
USA

Please Note
Do not make flight or hotel arrangements until you have received a confirmation letter from IMTEC Corporation with the correct date and location. A letter of confirmation will be sent to you once your registration form has been submitted and payment approved.

Terms and Conditions
Cancellations two weeks prior to event will be subject to a 25% administration fee. Cancellations less than seven days prior to the event are non-refundable. If you have any questions call 1-800-879-9799 (Toll Free US). For further assistance click here