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SEMINAR REGISTRATION FORM <br />Please complete this registration form and send it with your payment (check, credit card information, or <br />purchase order to: <br />Bureau of Labor and Industries <br />Technical Assistance for Employers <br />800 NE Oregon Street, Suite 1045 <br />Portland, OR 97232 <br />FAX: 971-673-1384 <br />Company Name: <br />Mailing Address: <br />GUe,wVt <br />;f <br />i v <br />City/State/Zip: T.N f4 L°h p 6 1~, ~7,yOa Telephone: <br />Confirmation only by a-mail: E-maail AII dd}}ress:~C tf • • W C~ ~S t~ (d Gl •~U~y EbL e -t7 C cS <br />Participant Name(s): J r«►f_LA ~Lt1lSh1 J <br />ct u ~ ~ S'Fc~rn 5 <br />Seminar Date: lcL- n 110 4- 1011 Seminar Location: RUC, W A to <br />Seminar Title: <br />How did you learn about BOLI Seminars? <br />❑ BOLI Email e~CBOLI Website ❑ Friend/Co-worker <br />❑ Radio/Newspaper Ad ❑ 'Flyer ❑ Other: <br />Total Payment Due: 4696.66 <br />❑ Check ❑ Purchase Order: <br />❑ VISA ;K MasterCard <br />Credit Card Number: 51105$a•001$15'X&6t Expiration Date: V/// <br />Printed Name: ✓ct-e- <br />'f Fa ^rfs6t?rPOf!~Q.Bwaau gfCaBn+ and Inoyaptec;tamproteaa anP(gyment, <br />r16ka, hdaaisol2nt~(o.Y1Re~ OPP~rtvr+itwe.ORdA!UGida1e80 M'A~wIdGlBarui <br />puhltc aacamm~dahrns free dbarlmtnaiian. <br />TA/Forms/Semimr_*gistration_B_2010 <br />