TECHNICIAN PROGRAM REGISTRATION

(in person only)

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REGISTER:

Technician Program - $195.00
Additional Lunch - $55.00

Luncheon is included in the Technician registration fee. Some attendees may need to add an extra one.

REGISTRANT'S CONTACT INFORMATION

First Name

Last Name

Credentials

If applicable.

Email

Specify email to be used for attendance certificate.

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

PAYMENT DETAILS

I wish to pay by:

Check
Credit Card

Total

$0.00

Company/Organization/Practice Name

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Person:

Phone:

Questions about registration?
Please contact Susan Umfer, sumfer@willseye.org