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*First Name:**
*Last Name:**
Title:
Employer:
Work Phone:
Cell Phone:
*Address 1:**
Address 2:
*City:**
*State:**
*Zip:**
*Address Type:**
*E-mail:**
How did you learn about this program?*	Other:
Industry Sector:
*Program:**
*Registration Type:**
*Program Date:**

Payment Method*:

If you selected "By Credit Card" as your Payment Method,
you will need to complete the payment process by clicking on the "Make Payment" button on the confirmation screen.

Cancellation and Refunds: Harrisburg University reserves the right to cancel or reschedule events at its own discretion. Should a program be cancelled by the university for any reason, a full refund will be issued. Cancellations received in writing to JReiner@HarrisburgU.edu from individual registrants more than 7 days prior to the start of a program or event are eligible for a 50% refund of fees paid. No refunds will be issued for cancellations received from individual registrants 6 or less days prior to the start of the event.

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*Number of Team Members:**
Team Member 2 First Name	Team Member 2 Last Name	Team Email 2
Team Member 3 First Name	Team Member 3 Last Name	Team Email 3
Team Member 4 First Name	Team Member 4 Last Name	Team Email 4
Team Member 5 First Name	Team Member 5 Last Name	Team Email 5
Team Member 6 First Name	Team Member 6 Last Name	Team Email 6
Team Member 7 First Name	Team Member 7 Last Name	Team Email 7
Team Member 8 First Name	Team Member 8 Last Name	Team Email 8
Team Member 9 First Name	Team Member 9 Last Name	Team Email 9
Team Member 10 First Name	Team Member 10 Last Name	Team Email 10

First Name:
Last Name:
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