REGISTRATION FORM for Mediator Certification Course

This registration form is designed to be pasted into 
an unformatted email message.  

Send the completed form to registrar@mediationworks.com

Other ways to register may be found at 
http://www.mediationworks.com/medcert3/register.htm

Karin Houck, Registrar 
Mediation Training Institute International
5700 West 79th Street
Prairie Village KS 66208-4604	
USA

Phone:   (913) 338-1113 
Toll-free:   (877) 338-1113 
Fax:   (913) 273-1919 

Email:  registrar@mediationworks.com
Web:  www.mediationworks.com

======== SECTION 1: PERSON WHO WILL BE ATTENDING ==================

Name:

Title:

Organization:

Address:

City:

State:

Zip:


Phone:
(May be needed to verify registration details.)

E-mail:
(Necessary to send confirmation letter.)


======== SECTION 2: COURSE CITY AND DATE ==================

Course city and date:

Pleaes tell us how you first learned of this program.  (E.g., search engine, colleague/friend, 
previous participant, link from other website, National Mediation, other?  . . . please describe)


======== SECTION 3: REGISTRATION FEE ==================

Regular registration fee: $1995 (US dollars)

See available discounts at http://www.mediationworks.com/mti/certconf/discsum.htm

CCA# (if any)*:

Registration fee:

======== SECTION 4: PAYMENT OPTIONS ==================

1)  Company purchase order number:
(or attach company P.O. form)

2)  Credit card number:
(Visa, MasterCard, or American Express)

Expiration date:
(required)

Name on card:

======== SECTION 5: CERTIFICATE ==================

Indicate the exact spelling of your name as you wish it to appear on your certificate:


======== SECTION 6: POLICIES ==================

Seats are limited.  Your place in the course is reserved by full payment.

Refund Policy:
Cancellations will be refunded, less a $100 administrative fee, until two weeks prior
to conference date. No refunds within two weeks of conference date.  Persons who 
cancel less than two weeks before conference date may transfer their registration 
to a later conference upon payment of a $100 rescheduling fee.  Request for 
rescheduling must be received within 30 days following original conference date.

* CCA#’s may not be combined with any other discounts (except government employee 
discount).  CCA#’s must be provided at the time of initial registration, and may 
not be applied retroactively.