Application for Enrollment

Print this form and mail or fax the completed form to the Modern Archives Institute.

APPLICATION FOR ENROLLMENT (Please fill in completely)
Please circle session preference: Jan. 25-Feb. 5, 2010 or June 7-18, 2010 Name____________________ (Indicate name as desired on course completion certificate.) Position__________________ Employer_________________ _________________________ Office Address: _________________________ _________________________ _________________________ Phone (office)___________________ (home)___________________ Fax______________________ E-mail___________________	Payment of $725 must be received between October 1 - December 1, 2009, for the winter institute. Payment for the summer institute must be received between October 1, 2009 - April 1, 2010. (Applications sent before October 1 should not include checks or credit card information. Those applications should be resubmitted between October 1 and the payment deadline, this time including the payment.) Until the deadlines, spaces may be tentatively reserved without payment. Credit card payments will be charged upon receipt. ( ) Government employee, requisition enclosed. ( ) Check enclosed. Make checks payable to: National Archives Trust Fund (MAI). Credit card: ( ) VISA ( ) MasterCard ( ) American Express ( ) DISCOVER card number________________ exp. date____________ cardholder signature_______________________ Fax or mail to: Fax number: 202-357-5950 Modern Archives Institute Room 301 National Archives Building 700 Pennsylvania Ave., NW Washington, DC 20408

APPLICATION FOR ENROLLMENT
(Please fill in completely)

Please circle session preference:

Jan. 25-Feb. 5, 2010

or

June 7-18, 2010

Name____________________
(Indicate name as desired on course completion certificate.)

Position__________________

Employer_________________

_________________________

Office Address:

_________________________

_________________________

_________________________

Phone

(office)___________________

(home)___________________

Fax______________________

E-mail___________________

Payment of $725 must be received between October 1 - December 1, 2009, for the winter institute. Payment for the summer institute must be received between October 1, 2009 - April 1, 2010. (Applications sent before October 1 should not include checks or credit card information. Those applications should be resubmitted between October 1 and the payment deadline, this time including the payment.) Until the deadlines, spaces may be tentatively reserved without payment.

Credit card payments will be charged upon receipt.

( ) Government employee, requisition enclosed.

( ) Check enclosed. Make checks payable to:
National Archives Trust Fund (MAI).

Credit card:
( ) VISA
( ) MasterCard
( ) American Express
( ) DISCOVER

card number________________
exp. date____________

cardholder signature_______________________

Fax or mail to:

Fax number: 202-357-5950

Modern Archives Institute
Room 301
National Archives Building
700 Pennsylvania Ave., NW
Washington, DC 20408

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