Registration Form

Cisco Networking Academy Program
Michigan Academy Conference:  October 19 - 20, 2004

IMPORTANT
Please fill out form completely.  Registration is due September 28, 2004.



Name: _____________________________________________________________________________________________


Title: ______________________________________________________________________________________________


E-mail (work): ___________________________________    E-mail (home): ____________________________________


Telephone # (work): _______________________________ Telephone # (home): _________________________________


Cisco Networking Academy: ___________________________________________________________________________


Work Address:  Street _________________________________________________________________________________


City ________________________________________________  State _________  Zip _____________________________

Registration Fee (Choose One):       ____ 2 Days - $90               ____ 1 Day - $75  (Tues or Wed ö circle one)

Select Payment Option:

____ Check #              _____________________________ (Make checks payable to Henry Ford Community College)

____ Credit Card #     ___________________________________________ VISA | MasterCard | Discover (circle one)

Name on card: __________________________________________   Amount Authorized:  _______________


Authorized Signature:  ___________________________________________  Exp. Date:  _________________

Check Shirt Size for Giveaways:
Men's Women's
____ Small ____ Small
____ Medium ____ Medium
____ Large ____ Large
____ Extra Large ____ Extra Large
____ XX Large

Please Note:  You must register and pay before September 28.  Late registrants may not be eligible for shirt giveaways.

Hotel Preference (used to determine size of reserved room block; PLEASE NOTE:  Participants are responsible for making their own hotel reservations)

____  Hampton Inn  ($89.95/night)
____  Courtyard by Marriott ($119/night)
____  Residence Inn ($124/night)

Return completed registration form with payment via U.S. Mail or fax to:

Michigan Academy Conference
Office of Career Education
Henry Ford Community College
5101 Evergreen Road
Dearborn, Michigan 48128
Fax #:  313-845-9800

For more information, contact Katie Fitzner at kfitzner@hfcc.edu or (313) 317-1570.