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Full Name:
Email:
Address:
Phone:
Please select desired workshop:
	November 16, 2007, 6:00 pm - 10:00 pm
	November 20, 2007, 10:00 am - 2:00 pm

	enter # of Adults / $25.00 each
	enter # of Children ages 4-18 / $15.00 each

I want to pay by:

	Check Payable to: IESSC
	Visa
	Mastercard
Credit Card Number:
Expiration Date:
Full Name on Credit Card:
Amount of Purchase:
Please enter your full name as your Digital Signature, Authorizing the charge to the above account:
Date:

	Make Checks Payable to: IESSC Mail to: IESSC c/o David Swank 4160 LaPlante Rd Monclova, Ohio 43542