PACT Registration

Please provide the following information:

Peer Assistance Coalition of Texas (PACT)

Adult Institute Registration Form

Billing Information

This is a(n)       Education  Service Center                                    
District                                          
School (Indicate District below) 

Organization Name
District Name
Contact Person
Position/Title
Mailing address
Address (cont.)
City
State
Zip code
Telephone
                           FAX
                       E-mail

Participant List

Name

School/Organization

 Position/Title

1

2

3

4

5

6

7

8

9
10
11
12

Fee Schedule

Earlybird (Registered by June 2, 2000): $100
Regular (Registered by August 11, 2000): $125
Late (Registered after August 11, 2000): $150

                              Fee  ( see above )
Times (X) Number of Participants  
                             total amount due   

Registration/Payment

Please make checks payable to:  PACT Adult Institute and mail to,                    

Prevention Education Associates, Inc.                       
7101 Highway 71 West, Suite 200                                             
Austin, TX 78735    

Please indicate comments below.


 

Additional Information:

Leni Serrano: leni@educating.org (e-mail)
512-288-9760

Kenneth Serrano
512-288-9760 (voice)
512-292-8949 (Fax)
serrano@educating.org (e-mail)

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