Online Low Vision Seminar
*Complete Name:
*Street Address:
City:
State:
Zip:
*Email Address:
*Phone Number:
Please Check Which Seminar You are registering for:
Live Seminar
Online Seminar
*Please indicate if you are OTR or COTA
Payment Method:
Credit Card
:
Master Card
VISA
Discover card
Credit card Number:
Expiration Date:
/
Print out Completed Registration Form and Mail or Fax with credit card information
Payment can also be made by phoning 409-363-3960
/
Fax: 409-515-1945
Money Order
Check
Credit Card Information
(including number and expiration date.)
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