ICN Fax Registration Form

      1. Print out this form.
      2. Fill out the information to register for a workshop or seminar.
      3. Fax completed form to ICN at 407-740-0368.

         Form may also be mailed to: ICN, Drawer 2970, Winter Park, FL 32790-2970

      Registration Information

    Event name_______________________________________________________

    Event date________________________  Price___________________________

    How did you hear about this ICN event? 
    ___Associates    ___Mail    ___Web Site    ___Email    Other:_________________

   Personal Information

     Name_________________________  Title____________________

     Company name_____________________________________________________

     Address__________________________________________________________

     Address 2nd line_________________________ Mail stop______________

     City _____________________________ State_______ Zip____________

    Country___________________________

    Telephone_________________________ Fax___________________________

    E-Mail________________________________________________

     ICN does not sell e-mail information to other businesses or list services.  However, we would like to
    include you on our e-mail list to notify you of upcoming events and announcements. If you do not wish
    to be on this list, please check here. _____

   Payment Information

     __ Please charge my ____MasterCard  ____Visa  ____AmEx  ____DinersClub

     Name on card ______________________________________________

     Card number _____________________________  Exp. date _________

     Customer Code (last 3 digits on back of card) ______________________

     __ Please bill me.  Purchase Order number ________________________

     __ Payment mailed with form.  Check number ______________________