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Registration Form |
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.