Registration Form

Please print & complete this form only if you wish to register by mail.

To register online, go to Event Calendar page

Name:_______________________________________________________________________________

Address:_____________________________________________________________Apt._____________

City:________________________________________________State:____________ Zip:____________

Telephone: (land line)____________________________(cell)___________________________________

Email:_______________________________________________________________________________

Registration Fees:

Speaker	Date	# Attending	Cost Each	Total $
Sichan Siv	January 21		$20
Dicky Grigg	March 7		$15
Dong Wang	March 25		$20
Sehba Sarwar	April 22		$20

Enclosed is my check for $___________ Check #___________

Your check will be your reservation

Mail to: Lifetime Learning             FOR OFFICE USE
P.O.Box 513 Date rcvd: __________
Brenham, TX 77834
                                                                                          Amt rcvd: $ _________
Phone:    979-337-4928
                                                                                                              # Attending _________
Email: info@lifetimelearningbrenham.org