Affidavit Writing Seminar

	Please fill in this form to register. If registering as an individual, payment must be made prior to seminar. Departments with Purchase Orders may pay at the seminar or can be invoiced. The red dots indicate required fields.
	Department
	Title
	First name
	Last name
	Street
	City
	State
	ZIP Code
	Business Phone XXX-XXX-XXXX
	Mobile or Home Phone XXX-XXX-XXXX
	Fax XXX-XXX-XXXX
	Email
	Repeat Email
	Payment Method			Pay Online by Credit Card Pay by Check Prior to Seminar Pay by Cash/Check at Door Bill My Department Other Please select one of the above payment methods
	Comments


	Press the button to confirm your registration. NOTE: Cancellations prior to 48 hours of any ICJE seminar date may be made without penalty. Cancellations within 48 hours of the seminar date will obligate registrants for the full amount of the seminar cost but may be applied to other seminars. Substitutions are welcome.