MAGNUS Leadership Registration

PERSONAL INFORMATION
Name*
First Last
Phone*
Email*
AGENCY INFORMATION
Your Agency Name*
Agency Address*
Street Address Address Line 2 City State ZIP Code
ENROLLMENT
Number Seats?*
Insert Students' Rank, full name, cell phone and e-Mail Address (all lower case) - Separate each with a ";"*

Example: Captain Mitch Jones, 804-000-0000, mjones@aol.org; Lt. Thomas Davis, 919-321-1234, tdavis@tcso.org; Sgt. Jack James, 910-324-1167, jjames@ecso.org
PAYMENT PROCESSING - $335 PARTICIPANT
Insert the location of the Workshop you are registering for:*
Workshop:
- 2-Days MAGNUS Leadership - $335 per Seat
Plan to Pay with:*
- Invoice - We will pay with a Check
- Invoice - We will pay with Credit card

PERSONAL INFORMATION