EQRC Mail-In Payment Form

Please print & complete this form and send in along with your check.

Make checks payable to EQRC

Mail to:  EQRC

              PO Box 24

              Cedarville, OH 45314

Included in your registration fee is all sessions (EQRC, AABSS, & CARE), up to 12 CEU credits, pre-conference workshops, and coffee breaks.

First Name:______________________________________

Last Name:_______________________________________

Email Address:_____________________________________

Phone Number:_____________________________________

⃞    Presenting or

⃞    Attending only

Payment Selection [Choose One]:

⃞   $260 Non-student rate

⃞   $180 Student & Retiree rate

⃞   $80 UNLV (faculty/staff or student) rate