Please print this page and fill in this form
| Name: ________________________________ | Company: ______________________________ |
| Address:_______________________________ | City: _____________________________ State:_______ |
| Zip:___________ Home Phone:_____________ | Fax: _____________ E-mail:_______________________ |
| Please List Date Attending: __________________________________________ |
Number Attending:_____________ |
| Total Amount Enclosed: (See Below) $___________ | Check Enclosed: _______ Check #____________ |
| OR: | |
| Credit Card Payment:____ VISA______ | MASTERCARD______ Exp. Date:_________ |
| Card #:________________________________ | # on back of card:______________ |
| Signiture:______________________________ | |
| Credit card payment: Please fax to: 609-426-1230 |
Check Payment: Please mail to: BICI 1200 Route 130 Robbinsville, NJ 08691 |