| On-line Reservation or Registration Form - One Day Immersion Events |
| Provide Course and Attendee Information |
| (*) - Required Field |
Please complete and submit one form per attendee |
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| First Name (*) |
A value is required. |
| Last Name (*) |
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| Job Title (*) |
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| Agency / Company (*) |
Agency / Company is required. |
| Address Line 1 (*) |
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| Address Line 2 |
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| City (*) |
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| State (*) |
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| Postal Code (*) |
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| Contact Phone Number |
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| Contact Fax Number |
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| Attendee Email Address (*) |
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| Your Email Address (if different) |
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Select Registration Fee - 1 Day Courses |
- $599 per person
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Note - Registration takes priority over unpaid reservations. Government rates apply to employees of qualifying Federal, State or Local government entities only. For questions please call (703) 825-5588. |
Payment Options / Instructions |
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Please enter credit card details below. Registration is completed upon credit card authorization. For Company Check, Government Purchase Order and other forms of payment, registration will be complete following receipt and confirmation of payment made in full to: "CPIC Solutions Corp." and mail payment to:
P.O. Box 923, Great Falls, VA 22066
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Credit Card Information |
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| Credit Card Number |
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| Expiration Date - mmyyyy |
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| Name on Card |
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| Billing Address - Street |
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| Billing Address - City |
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| Billing Address - State |
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| Billing Address - Zip Code |
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| Security Code |
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| IMPORTANT INFORMATION: Please Read Below |
| Cancellation Policy: You may designate a substitute in writing any time before the workshop. Cancellation requests must be sent in writing (email or fax) and will be subject to a $100 processing fee. No cancellations are accepted within 2 (two) weeks prior to the workshop start date. PLEASE NOTE: No shows will be liable for the entire registration fee. In the rare event that a program is cancelled or postponed, please note our reimbursement is limited to paid tuition only. We have the right to refuse registration to any attendee at any time. |
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Please make a selection. |
By checking the box, you indicate that you have read, and agreed to the terms of the Cancellation Policy as stated above. |
Click Submit at the bottom of this form -
you may also request additional information below
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