Registration Form for 2008 Municipal Clerk Institute and Academy

 Certified Municipal Clerk Institute $650.00
XPAD 1101 200825 CN 90007

 Master Municipal Clerk Academy $475.00

XPAD 1200 200825 CN 90009

If registering more than one participant, please duplicate this form.

Date ¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾

Name (First, Middle, Last)¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾

Clerk of¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾

Street Address¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾

City¾¾¾¾¾¾¾¾¾¾¾State¾¾¾¾¾¾¾¾¾¾¾¾¾ZIP¾¾¾¾¾¾

Phone day¾¾¾¾¾¾¾¾¾¾¾Evening¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾

Fax¾¾¾¾¾¾¾¾¾¾¾¾¾Email¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾¾

 This is my ¾¾ year at the Institute This is my ¾¾¾ year at the Academy



Please mail with check or company purchase order made payable to ODU

Non-Credit Operations

138 Gornto, TELETECHNET Building

Old Dominion University

Norfolk, VA 23529

Or fax to: 757-683-5443 (using VISA or MasterCard)

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Print name as it appears on card

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