Assistive Technology Applications Certificate Program
ATACP FastTrax Registration Form for November 19-20, 2008 at World Congress on Disabilities Expo in Jacksonville, Florida
1.Registrant Information:  All fields are required
First Name:  
Last Name:
Job Title:
Organization:
Mailing Address:
City:
State:
Zip Code:
Country:
Work Number:
Fax Number:
Home Number:
International Number:
Email:
Website:
Date of Birth:

2.Disability Accommodations:  Place an "X" before or after the accommodation(s).  There are 7 accommodations to choose from.
None
Assistive Listening Device
Braille
Large Print
Disk (ASCII)
Sign Language Interpreter
Other

3.How did you hear about us?  Place an "X" before or after the item(s).  There are 4 items to choose from.
Center on Disabilities' Website	  
Information received via email	  
Materials received in the mail
Other (please specify):

4.Fees: Place an "X" before the training.  There are 2 items.
FastTrax 2 Day and WCD Expo at Jacksonville, FL - $1,775.00


5.Total Amount Enclosed:

6.Payment Options:  Place an "X" before a payment method you wish to pay by.  There are 3 items to choose from.
Purchase Order Number:
Check payable to California State University Northridge Center on Disabilities (Check number):
Credit Card (Select One):	 AMEX	  MasterCard	  VISA
Cardholder's Name:
Credit Card #:
Credit CardExpiration Date:
Signed By:
Date Signed:

No refund will be paid once the on-line username and password have been accepted.  Individuals/organizations will be expected to pay the full amount of the ATACP course.  Refunds will be made (less the $50 cancellation processing fee) if  1) request for cancellation is received in writing 30 days prior to live training date and 2) on-line username and password has not been used.

For further information, please contact:  California State University, Northridge Center on Disabilities
18111 Nordhoff Street, Bayramian Hall 110 Northridge, CA 91330-8340
Phone (818)677-2578  V/TTY Fax (818)677-4929 Email codtraining@csun.edu Web Site www.csun.edu/codtraining