EXAM REFRESHER TRAINING SESSION PRE-REGISTRATION

Please provide the following contact information:

Name
Title
Organization
Mailing Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

Please provide the location and date you would like to attend:

Location:           

Date:                 

Check one:  I am attending the:         Water Session          

                                           OR       Wastewater Session

Choose one of the following options:

Registration Fee: Member: $125.00 Registration Fee: Non-Member $150.00

Choose your payment option:

A. I will send a check in the mail. B. I will call the MRWA office to give credit card information. C. Please Bill Me.

Please print this form - this is your invoice.   Make payment to: Minnesota Rural Water Association                            217 12th Avenue SE                            Elbow Lake, MN  56531