CPE Certified Port Executive TM

CPE Certified Port Executive TM

Participant Information

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NAME (print clearly for certificate purposes) TITLE

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COMPANY ADDRESS

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CITY PROVINCE / STATE COUNTRY POSTAL / ZIP CODE

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BUSINESS PHONE PHONE (OTHER) FAX

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E-MAIL WEBSITE

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LOCATION DATE

Social Media Contact Information:

PERSONAL TWITTER ACCOUNT: __________________________ COMPANY TWITTER ACCOUNT:_______________________________

WOULD YOU LIKE TO JOIN OUR LINKEDIN GROUP FOR CPE UPDATES? □ Yes □ No

Registration Fee USD $ 3995.00

Total payment USD $3995.00

[ ] Visa [ ] Master Card

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Credit Card Number Expiration Date

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3 Digit Security Code

Name of Cardholder: Cardholder’s Signature

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Card owner agrees to pay total in accordance with agreement governing use of such card | International transactions may be subject to an additional currency conversion fee | Charge backs and declined transactions may be subject to an additional handling fee | MacDonnell reserves the right to re-schedule courses, cancellations will be carried forward to the next available CPE course in the region, no refunds.