Your First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Country:

Phone Number:

E-mail Address:

Workshop name:

Workshop dates:

How did you find out about TSI?

already in training

personal contact/referral

conference or presentation

flyer/advertisement

press article

browsing the web

other: please specify

How will you be paying?

I will fax (434) 923-8291 or call with my credit card info (434) 923-8290

I will be mailing a check (payable to TSI)

Reminder: If faxing or calling with credit card info, you will need to let us know:

• Visa or Mastercard
• name on card (if different from above)
• street address & zip code of cardholder (if different from above)
• card number
• expiration date