To Register print and mail or fax this form to:
Safe-Capture International, Inc.
P.O. Box 206
Mt. Horeb, WI 53572 USA
Fax: (608) 767-3072
| Register For: |
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| O Chemical Immobilization Animals: Multi-Species
O Chemical Immobilization of Non-Human Primates |
| Program Location:
_______________________________ |
Program Dates:
__________________________________ |
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| Registrant Name(s):
__________________________________________________________________________________ _________________________________________________________________________________________________ |
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| Agency/Farm/Ranch:
______________________________ |
Mailing Address: ___________________________________ |
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| City: ___________________________ | State: _______ | Zip: _______________ | Tel: ______________________ |
Fax: _______________________________________ |
Email: __________________________________________ |
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** Early Registration Fee: (Save $50 if you register more than 30 days prior to the program date!)
| Early Registration | General Registration | Student Registration | |
| $575 | $625 | $325 |
Total Number of Registrations: _______________ Total Registration Fee enclosed: _______________
(Check, VISA, MasterCard Accepted): Card#: __________________________ Exp: ____________
| If you cannot attend this program, but would like to be on a mailing list for future programs, please check here and return this form |