To fax in your reservation,
print off this page, fill in the blanks
and fax to Instruct-online at 319-626-7257:

Catalog Number : wpagn1467-iol
Webplay Name : EOC Part 4: Emergency Management, Part 1
Speaker : Bartels, Dinney, Jansen-Adams, Wagner
Price : $195 for 2 week access

All the information below is required:
Organization's Name : ______________________________
Address : ____________________
City/State/Zip : ____________________
Contact Name : ____________________
E-mail address : ____________________
Phone Number : ____________________

___ Pay by Check (Payable to : Instruct-online)
___ Pay by PO (Payable to : Instruct-online)
          PO#____________________
___ Pay by Credit Card (Mastercard or Visa)
          Card Number____________________
          Name on Card____________________
          Expiration Date______
          Credit Card Verification Number (from back of card)______