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

Date:  Nov. 16, 2010

10:00am - 1pm

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PRAXIS I -- WORKSHOP REGISTRATION FORM

ATTENDEE INFORMATION

Name: ____________________________________________________________________ Telephone: _______________________

Address: ____________________________________________________________________

   City/State/Zip: _________________________________________________________________

Email Address: ______________________________________________________________________

Date Attending:  Nov. 16, 2010 Time: 10 a.m. - 1:00 p.m.

Location: TBA   Registration Fee: $10.00

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

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

Security Code ___ ___ ___ (Last 3 numbers on back of card)

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