19th
Annual Workshop on SIMS
Mail/Fax/Telephone Payment Form
If registered online, Right Click
to PRINT this form to make payment.
Complete and Mail (with payment)
or Fax (with credit card information)
to the address below.
If
NOT registered online, use
THIS FORM (PDF format) to
register and pay by Mail or Fax.
Name: _____________________________
Company: __________________________
Address: ___________________________
Address: ___________________________
City:
Phone: ____________________________
Fax: ______________________________
Credit Card:
___VISA ___MasterCard
3 or 4-Digit Reference Number: ________
Card Number: _______________________
Expiration Date: ____________
___________________________________________
Card Holder’s Name (Please print)
___________________________________________
Card Billing Address (Please print)
____________________________________________
Signature of Card Holder
Mail or Fax to:
Christa
Baumgardner
Annual Workshop on SIMS
P.O. Box 1480
Edgewater, Maryland
21037
1-866-396-8620
Facsimile: (410)-451-7373
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List Name(s) payment is for below.