REGISTRATION FORM:

Please print or type.
Incomplete Applications will delay the registration process.
Registrations must be received no later than 25 days before the scheduled seminar date.

Name Badge Reference
Mr./Ms.	Title
Organization
Address
City	State Zip
Phone	Fax
Email
Check here if you do NOT wish to receive e - mail from us regarding Training Institute events and programs
Check here if you have special needs addressed by the Americans with Disabilities Act
Check here if you have attended a Training Institute before
Are you enrolled in a Professional Certificates Program of Study? Yes No
	If yes, which one?
Which of the following best describes your organization?
Government agency Community-based development organization Financial institution
Tribal government or tribal nonprofit Other (please specify)
How long have you been in your current position?
less than 1 year 3-4 years 5 or more years
Which of the following best describes your race? Please choose all that apply
American Indian or Alaska Native Asian Black or African American Hispanic or Latino
Native Hawaiian or Other Pacific Islander White Other
Courses requested
Use course numbers only. Please include second choices in case your first-choice courses are full.
Tuesday and Wednesday Thurthday Friday and Saturday Total number of days   Tuition per day   Tuition and fees   First Choice X $175 = $   Second Choice
Nonrefundable / Nontransferable /registration fee $   Computer lab fees (see course description)   Nonrefundable / Nontransferable processing fee   Total due $
Payment must accompany your registration form. Registration must include credit card information.
Payment Information   Check enclosed (payable to Neighborhood Reinvestment). Check number Purchase order attached. Purchase order number Visa MasterCard American Express Card # Exp.date   Name as it appears on card   Authorized signature : Mail registration and Payment to: BLACK CRYSTAL ENTERPRISES P.O. BOX 794734 DALLAS, TEXAS 75379-4734 or click the "Submit" Button Below: