Kelley Assessment & Planning Services

WORKSHOP REGISTRATION FORM

Please Type or Print

Name _______________________________________________________________________

Dept/Program ________________________________________________________________

Institution ___________________________________________________________________

Address _____________________________________________________________________

City/State/Zip _______________________________________________________________

Work Phone _____________________________ Home Phone ___________________________

Fax _________________________________ E-mail __________________________________

List the workshop location: _______________________________________________________

List the workshop date: __________________________________________

The registration fee is $100. Lunch is provided.

Please mail a completed form and check payable to KAPS to:

Larry H. Kelley
824 N Gay Street
Auburn, AL 36830

Contact aukelley@aol.com for additional information.