ONLINE GROUP REGISTRATION

INSTRUCTIONS:

1. PLEASE COMPLETE THE FOLLOWING FORM ON SCREEN.
2. CLICK THE SUBMIT BUTTON AT THE BOTTOM.

DATE OF SEMINAR:
Select Date Dayton, Ohio - March 10, 2012

GROUP CONTACT PERSON'S NAME:

ADDRESS:

CITY, STATE, ZIP:

PHONE (Including Area Code):

E-MAIL:

RE-ENTER E-MAIL:

NAME OF FIRE DEPARTMENT:

HOW DID YOU LEARN ABOUT THIS OPPORTUNITY?

Select At a previous Fire Nuggets Seminar Fire Nuggets E-mail Fire Nuggets Mailer Firenuggets.com Web Site Firehouse Magazine At a Firehouse Event Firehouse.com Web Site Firehouse E-mail Firehouse Mailer Word of Mouth Other

To register a group with THE SAME contact information, please add names below:

PLEASE INDICATE YOUR CHOICE OF PAYMENT OPTIONS:

I prefer to pay by credit card.

(If you choose this option, you will be contacted at the e-mail address you indicated above with instructions on how to submit your credit card payment.)

Tell me how to make payment using a purchase order/voucher.

I prefer to pay our registration fee by mail. Send your payment to:

Fire Nuggets
P.O. Box 28911
San Diego, CA 92128-0911

10-day cancellation notice required for full refund.

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