LID Certification Exam Registration Form

LID Certification Exam Registration Form
First Name: Last Name:
Organization/Agency:
Address:
City:
State:	Zip:
Phone:	Fax:
Email Address (please make sure to enter your address correctly to insure confirmation):
Registration Fee: $200 We accept Visa, MC or checks. If paying by check, make your check payable to: NC State University Mail your check to: NCSU-BAE Campus Box 7625 Raleigh, NC 27695-7625 Attn: Christina Shepard If paying by Visa or Mastercard, please call 919-513-2192 or 919-515-6780 with your credit card information (card #, name on card, expiration date, and billing address).
I will mail in a check I will call with my credit card information
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