PALMETTO STATE TEACHERS ASSOCIATION

Please print this form and return to:

Palmetto State Teachers Association,

2015 Assembly Street, Columbia, SC 29201

Or, fax to 803-376-1960

Nov. 16, 2010

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PRAXIS II/PLT -- WORKSHOP REGISTRATION FORM

ATTENDEE INFORMATION

Name: ____________________________________________________________________ Telephone: _______________________

Address: ___________________________________________________________________________

City/State/Zipcode:____________________________________________________________________

Email Address: ______________________________________________________________________

Date Attending: Nov. 16, 2010 Time: 2:00 - 5:00

    Location:TBA

Registration Fee: $10.00 (PSTA Member) $25.00 (Non-Member)

Method of Payment (check one): _____ Cash ____ Check ____ VISA/MasterCard

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ exp. date: __ __ __ __

security code ___ ___ ___ (last 3 numbers on back of card)

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