IAEDP 2005
Symposium Payment Form
If registered online, Right Click
to PRINT this form to make payment.
Complete and Mail with payment or
Fax to the address below.

No refunds after July 15, 2005.
$35 processing fee applied to refunds
prior to July 15, 2005.

If NOT registered online, use 
THIS FORM (PDF format) to
register and pay by Mail or Fax.

Name: _____________________________

Company: __________________________

Address: ___________________________

Address: ___________________________

City: ___________ State: ____ Zip: _____

Phone: ____________________________

Fax: ______________________________

Credit Card:
 ___VISA    ___MasterCard    ___American Express

3 or 4-Digit Reference Number: ________   

Card Number: _______________________

Expiration Date: ____________ 

___________________________________________
Card Holder’s Name (Please print)

____________________________________________
Signature of Card Holder

Mail or Fax to:
IAEDP
2005 Symposium Registration
PO Box 1480
Edgewater, MD 21037-7480
E-Mail: Christa Baumgardner
Phone: 410-451-9223
Fax: (410) 451-7373
***********************
List Names payment is for below.