Form

"How to respond to WISHA Inspections and Citations"
SAFTEY Mini-Seminar

Registration

Mon., November 14, 2005
8:30 a.m. - noon
ESD #112
2500 NE 65th Ave.
Vancouver, WA 98661

Thurs., December 8, 2005
12:30 - 4:00 p.m.
Tukwila Community Center
12424 42nd Ave. S.
Tukwila, WA 98168

* Required Information

Mini-Seminar Fees

WSIA Member Registration	$69.00
WSIA Member Additional Registrations	$49.00
Non-Member Registration	$75.00

*Method of Payment

Visa

Mastercard

Check

Invoice Company

Purchase Order

Purchase Order No.

Credit Card Number (16 digits, no spaces):
Cardholder Name:
Expiration Date:

Please fill out a separate form for each additional attendee.

Washington
Self-Insurers Association
1401 Fourth Ave. East
Suite 200
Olympia, WA 98506
Phone: (800) 736-7296
(360) 352-8172
Email:
info@WSIASSN.org