General Seminar Registration Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=200 BGCOLOR="#333366" TEXT="#080000" background="127c8c00dkcfsz.png"> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE="Clinicworks, Inc, for the Best and Most "><U><B>Home</B></U></A><B>  </B></div> <bR> <div> <A HREF="avimark_training_seminars.htm" TARGET="_top" TITLE="Training Seminars"><U><B>Back to</B></U></A></div> <div> <A HREF="avimark_training_seminars.htm" TARGET="_top" TITLE="Training Seminars"><U><B>Seminars Page</B></U></A></div> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <B><IMG SRC="3ef06500.jpg" border=0 width="774" height="80" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <I><B><IMG SRC="1c43e410.gif" border=0 width="62" height="65" ALIGN="BOTTOM" HSPACE="5" VSPACE="0"></B></I><FONT SIZE="2" COLOR="#FF0000" FACE="Arial" ><I><B>Helping Your Clinic Grow Through Practical Informatics!      </B></I></FONT></div> <div> <I><B>Assistance for any size Veterinary Hospital using the AVImark Practice Management System...</B></I></div> <div> <I><B>Training, Software, Hardware, Networking and Total Integration</B></I></div> <bR> <div> <B>General Seminar Registration Form</B></div> <div>      </div> <div>  </div> <div> <B>Printable Seminar Registration Form:</B></div> <div> <B>Please </B><FONT SIZE="4" COLOR="#000000" FACE="Verdana" ><B> <script> // (C) 2000 www.CodeLifter.com // http://www.codelifter.com // Free for all users, but leave in this header function printWindow(){ bV = parseInt(navigator.appVersion) if (bV >= 4) window.print() } </script> <a href="javascript:printWindow()">Print This Page</a>  </B></FONT><B>, then mail your completed registration to: </B></div> <bR> <div> <B>ClinicWorks.com</B></div> <div> c/o Paul M. Schmitz, DVM</div> <div> 1616 S. Beech Ave.</div> <div> Broken Arrow, OK 74012</div> <bR> <div> <B>Questions?  Need Help?</B></div> <div> Phone: (918) 259-9460</div> <div> Cell: (918) 605-7046</div> <bR> <div> <B>FAX # to Send this form to: (786) 513-0369</B></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="738" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 WIDTH="722"><div> <B>Contact Name/Title:</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 WIDTH="722"><div> <B>Practice Name:</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 WIDTH="722"><div> <B>Address: </B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="200"><div> <B>City:</B> </div> </tD> <tD VALIGN=CENTER COLSPAN=2 WIDTH="187"><div> <B>State:</B></div> </tD> <tD VALIGN=CENTER WIDTH="329"><div> <B>Zip: </B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=2 HEIGHT= 19 WIDTH="307"><div> <B>Phone:</B></div> </tD> <tD VALIGN=CENTER COLSPAN=2 WIDTH="412"><div> <B>Fax:</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 WIDTH="722"><div> <B>E-mail:</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 16 WIDTH="722"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="722" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 WIDTH="722"><div> <B>Please list the attendees with First and Last names:</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #1:                                                                         </B>Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #2:                                                                         </B>Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #3:                                                                        </B> Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #4:                                                                         </B>Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #5:                                                                 </B>        Fri / Sat / Sun ?<B> </B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #6:                                                                        </B> Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER ROWSPAN=2 COLSPAN=4 HEIGHT= 1 ><NOBR><div> <B>Attendee #7:                                                                         </B>Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #8:                                                                         </B>Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #9:                                                                         </B>Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 ><NOBR><div> <B>Attendee #10:                                                                     </B> Fri / Sat / Sun ?</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 20 WIDTH="722"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="722" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 23 ><NOBR><div> <B> Please list the Seminar Dates you wish to attend:</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER ROWSPAN=2 COLSPAN=4 HEIGHT= 1 ><NOBR><bR> <div> <FONT SIZE="3" COLOR="#000000" FACE="Verdana" ><B>   </B></FONT><B>REGISTER BY EARLY BIRD </B><FONT SIZE="4" COLOR="#FF0000" FACE="Verdana" ><B>DEADLINE*</B></FONT><B> AND SAVE!</B></div> <bR> <bR> <div> <B><U>Phoenix, AZ Seminar</U></B></div> <div> <B> Phoenix -  Fri, Oct 3rd - 1st Session         ____# ATTENDEES 10/03/08</B></div> <div> <B> Phoenix - Sat, Oct 4th - 2nd Session        ____# ATTENDEES 10/04/08</B></div> <div> <B> Phoenix - Sun, Oct 5th - 3rd Session       ____# ATTENDEES 10/05/08</B></div> <bR> <div> <B>  </B><FONT SIZE="2" COLOR="#FF0000" FACE="Arial" ><B>* Phoenix, AZ - Early Bird Registration Ends Midnight Friday, Sept 19th, 2008</B></FONT></div> <bR> <div> <I><B> “We highly recommend attending all sessions!”</B></I></div> <bR> </NOBR></tD> </tR> <tR> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 186 ><NOBR><div> <B>Register by the Early Bird Deadline to save on each attendee!</B></div> <bR> <bR> <div> <B><U>Phoenix, AZ Seminar</U></B></div> <div> <B>Total Registrants: ____   @  $200.00* per person for 1 day        = $______ Total</B></div> <div>  <B>  </B><FONT SIZE="2" COLOR="#FF0000" FACE="Verdana" ><B>* $250 if received after Early Bird Deadline of Sept 19, 2008</B></FONT></div> <div> <B>Total Registrants: ____   @  $300.00** per person for 2 days   = $______ Total                               </B></div> <div> <B>   </B><FONT SIZE="2" COLOR="#FF0000" FACE="Verdana" ><B>* $350 if received after Early Bird Deadline of Sept 19, 2008</B></FONT></div> <div> <B>Total Registrants: ____   @  $400.00** per person for 3 days   = $______ Total                               </B></div> <div> <B>   </B><FONT SIZE="2" COLOR="#FF0000" FACE="Verdana" ><B>* $450 if received after Early Bird Deadline of Sept 19, 2008</B></FONT></div> <bR> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 16 WIDTH="722"><div> <B>PLEASE PRINT LEGIBLY </B></div> </tD> </tR> <tR> <tD VALIGN=CENTER ROWSPAN=3 COLSPAN=4 HEIGHT= 1 ><NOBR><div> <I> </I></div> <div> <I> Please make checks payable to</I><I><B> Clinicworks, Inc.</B></I></div> <bR> <div> <I> Mail check payments to</I>: <FONT SIZE="3" COLOR="#000000" FACE="Verdana" ><I><B>Paul M. Schmitz, DVM</B></I></FONT></div> <div> <B>                                                  1616 S. Beech Ave.</B></div> <div> <B>                                                   Broken Arrow, OK 74012</B></div> <div>  </div> <div> <B>Please Check here if paying by mailed Check ____</B></div> <bR> <div> <I><B> --> Sorry, checks not accepted after the Early Bird Deadline as listed above</B></I></div> <bR> </NOBR></tD> </tR> <tR> </tR> <tR> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 98 ><NOBR><div> <B>                                              </B></div> <div> <B><IMG SRC="3fd8a460.png" border=0 width="138" height="70" ALT="Bitmap Image" ALIGN="LEFT" HSPACE="10" VSPACE="6"></B></div> <div> <B>Major Credit Cards Accepted Online or via Phone Virtual Terminal </B></div> <div> <B> Check here ___ if registering and paying "online".  </B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 91 ><NOBR><div> <B>Additional Comments or Questions:</B>_________________________</div> <div> _______________________________________________________</div> <div> _______________________________________________________</div> <div> _______________________________________________________</div> <bR> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 141 WIDTH="722"><div> <B>Cancellation Policy:</B></div> <div> You may cancel your registration up to 10 days before the seminar.  Your registration fee will be refunded, <U>less a $25.00 service charge, per day, per person canceled</U>.  If you need to cancel less than 5 days prior to the seminar, you may:  1) send a substitute from your practice or 2) transfer your registration fee to another Clinicworks AVImark Seminar of your choice within 12 months.  </div> <bR> <div> <I><B> --> Sorry, checks not accepted after the Early Bird Deadline as listed above</B></I></div> <bR> </tD> </tR> </TABLE></div> <bR> <div> * Remember, if you prefer, you may register and pay (by check or credit card) using this</div> <div> mail-in / fax-back form or you can register and then pay online using our secure PayPal</div> <div> enabled shopping cart, or by using your Visa, Mastercard, Discover, American Express</div> <div> or eCheck.  </div> <bR> <div> <B> <table border="0" cellpadding="2" cellspacing="0" align="left"><tr><td align="left"></td></tr> <tr><td align="left"><a href="#" onclick="javascript:window.open('https://www.paypal.com/cgi-bin/webscr?cmd=xpt/popup/OLCWhatIsPayPal-outside','olcwhatispaypal','toolbar=no, location=no, directories=no, status=no, menubar=no, scrollbars=no, resizable=no', width='400', height='350');"><img src="https://www.paypal.com/en_US/i/bnr/horizontal_solution_PPeCheck.gif" border="0" alt="Why PayPal?"></a></td></tr></table>  </B></div> <bR> <bR> <bR> <bR> <bR> <div> <A HREF="http://www.globalscape.com" TARGET="_top" TITLE="http://www.globalscape.com"><U><I><IMG SRC="1ce54290.png" border=0 width="84" height="41" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></I></U></A>Copyright<FONT SIZE="2" COLOR="#111111" FACE="Symbol" >â </FONT>2008 Clinicworks, Inc.</div> <bR> <bR> <bR> </td> </tr></table></body>