EMS, LLC Educational Opportunities

EMS, LLC Office – 10654 Justin Drive, Urbandale, IA – (515) 278-8002

______           I plan on attending the Thursday, July 21, 2005 MORNING EQIP Session

______           I plan on attending the Thursday, July 21, 2005 AFTERNOON EQIP Session

Registration Information:          □ Mr.    □ Ms.   □ Mrs.  □ Dr.   /      □ Female     □ Male

First Name                              Middle Name (Initial)                            Last Name

                                                                                                                                               
Organization/Company                       Dept/Subunit                           Job Title

Email                                                                                                   Day Phone

Mailing Address Line 1                                                                        Evening Phone

Mailing Address Line 2                                                                        Fax Number

City                                          State                Zip Code                      County

□ Please contact me, I have special dietary needs and/or need accommodations for a disability

Registration Fee

□ EQIP (Morning Session 9 – 12)               $249.00

□ EQIP (Afternoon Session 1 - 4)               $249.00

The course fee includes course information supporting each topic area, breaks and lunches during the course. If you cancel, you will get a refund, minus a $30 administration fee. If you cannot attend the course, you may send a substitute. Call registration clerk at (515) 278-8002 if you have a change of plans.

Payment Options

Make Check Payable to ‘EMS, LLC’ and Mail to:        EMS, LLC, Registration Clerk, P.O. Box 14586, Des Moines, IA  50306

Please charge my:                  Visa                MasterCard    Exp. Date:                              

Account Number:                                            Signature: