January 2009 Registration Form

Institute Location - Tokai University Pacific Center

2241 Kapiolani Blvd (between McCully and University)

Registration Form
Pacific Institute of Chemical Dependency 2008 January Institute
Deadline for refunds: January 9, 2009 One form per registrant. Duplicate form if necessary.

Name Work Phone Fax

Mailing Address City State Zip

Current Employer Address

E-mail Address (we're moving toward future registration and correspondence being done via email for faster more timely responses)

PLEASE CHECK THE BOX NEXT TO THE WORKSHOP(S) YOU WILL BE ATTENDING

Pat Love: Helping Disconnected Clients Reconnect
January 22 & 23, 2009 ($150 if received by January 9, 2009. $175 after that date)

Total Due:

Submit Registration and proceed to Paypal

Otherwise, print form and submit with payment

P.O. Enclosed
Check Enclosed
P.O. to follow (must be recieved by training date)

MAIL THIS FORM WITH CHECK PAYABLE TO PICD TO:
PICD
P.O. Box 1233
Kailua, HI 96734-1233

For more information email picd01@picd.org