Seminar Information Request Form Home Seminar Information Request Form Please complete this form to receive information on Brookes On Location seminars. (You can also call toll-free 1-800-638-3775 or 410-337-9580; please review the questions on this form before calling.) 1. Professional Development InterestsWhich seminar would you like to be contacted about?* Do you already use the tool(s) that correspond(s) to this seminar topic?* Yes No How did you hear about this seminar?*Please selectIn a mailingOn the webIn an ad in a bookIn materials included in my last package from BrookesAt a conferenceIt was recommended by a friend/colleagueFrom a customer service representiative at Brookes2. Contact InformationFirst name* Last name* Title* School/Organization* Address* Country*United StatesCanadaCity* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificProvince*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonZip/postal code* Phone* Fax* Email address* How do you prefer to receive a reply?* Email Phone Fax Type of organization* Ex: Child Care, Preschool, Head Start, College/University, etc.3. Seminar InformationTelling us more about your needs will help us give you a more detailed reply. It's OK if you're not sure yet!Approximately how many people would you like to include?* Not sure 1-10 11-25 26-50 51-100 More than 100 When would you like to hold the seminar?Preferred Date* Secondary Date How long would you like the seminar to last?* Ex: 1 day, 2-days, etc. Comments or questions?*Security CheckPhoneThis field is for validation purposes and should be left unchanged.
