ALA Artifact

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ALA Artifact

  1. 1. PLA Webinar Registration Form <br />Mail or fax this form with payment to the address in the box. <br />All required fields must be completed on this form to reserve space in the course. <br />Required Fields are indicated with an asterisk* <br />*Webinar/Course Title: <br />Dive into a Good Book: Great Summer Reads to Recommend to Your Patrons_________________________________________________________ <br />*Webinar/Course Date/Start Date: __Tuesday July 19, 2011__________________________________ <br />ALA Member Number (if available): _____1280023______________________________ <br />*First Name:_Robert_____________________________________________________ <br />*Last Name:__Johnson____________________________________________________ <br />Title: _____Librarian_(Student)_____________________________________________________ <br />*Organization Name:__Sam Houston State University_____________________________________________ <br />*Org. Mailing Address: <br />________________________________________________________________ <br />________________________________________________________________ <br />Preferred Mailing Address, if other than organizational address: <br />103 N. Wagon <br />Wheel_____________________________________________ <br />Boerne, TX _78015_____________________________________________________________ <br />*Daytime Phone: <br />_(830) 755-6305_____________________________________________ □ Work □ Home <br />*E-mail: ___rtj004 @shsu.edu_______________________________________________________ <br />How did you hear about this course? □PLA Email □Other (please specify): ___ALA website______________________________________________________________ <br />*Registration Fee: Place a check mark in the appropriate box. Group registration includes one login. <br />□ $28 PLA Members □ $31.50 ALA members □ $35.00 Non-members <br />□ $129 Any Size Group <br />*Payment Method: Place a check mark in the appropriate box. Payment or Purchase Order must accompany registration. <br />□ Check Enclosed (payable to the American Library Association) <br />□ Purchase Order Number (include a copy of the order with this form): __________________________________________________________________ <br />For credit card orders, please complete the following (all required): □ VISA □ Master Card □ American Express <br />Card Number: __________________________________________________________ Expiration: _______/_______ <br />Name on Card (print please):____________________________________________________________________________ <br />Signature:__<br />Robert Johnson____________________________________________________ Date:__06/30/2011_______________________<br />

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