The Mid-South Basic Economic Development Course

	Registration Form PLANNING STRATEGICALLY FOR THE NEW ECONOMY IEA Center for Economic Development Education The University of Arkansas at Little Rock December 4-6, 2007 Please submit by November 29, 2007 Please fax a copy of your Registration Form to us immediately, even if you are using it to process a payment. If registration has not been confirmed within 48 hours, please call Rita DeLoney at (501) 569-8519.Without the Registration Form we cannot reserve your seat for the course. Thank you.
	Mr. ____Mrs. ____Other (specify) _____________________________________________ Name: ___________________________________________________________ Title: ____________________________First Name Preferred on Badge: ________________ Economic Development Affiliation (organization name): ________________________________________________________________________ E-mail address: ____________________________________________________________ Street or P.O. Address: _______________________________________________________ City, State, Zip: ____________________________________________________________ Work Phone: __________________________ Fax: _____________________________ Alternate Phone: __________________________ Education (please check highest level attained) High School ____ Some College ____ Bachelors ____ Masters ____ Doctorate ____ What is your economic development role? ____E.D. Professional ____E.D. Agency Staff ____Community Developer ____Community Volunteer ____Elected Official ____Business Person ____Private Consultant Other (Specify) _______________________________________ Please check the one category that best describes the economic development group with which you are most closely affiliated. ____Chamber of Commerce ____Economic Development Organization ____State Agency ____Federal Agency ____Education ____Utility ____Transportation Agency ____City/County Government Agency Other (specify) _______________________________________ At what geographic scale do you most frequently participate in economic development? ____City ____County ____Multicounty ____ State ____Multistate ____Federal Fees: $275 Total $ ______ (Enclose check or purchase order copy, payable to UALR Institute for Economic Advancement) or __________ invoice me. Signature __________________________________________Date _________________ Please indicate any special dietary or other needs you may have during the course. Please fax a copy of your Registration Form to us immediately, even if you are using it to process a payment. Without the Registration Form we cannot reserve your seat for the course. FAX completed form to 501-569-8538 or send to: IEA-ED Education Community Analysis Course Room 422 2801 South University Ave. Little Rock, AR 72204-1099

	Community Analysis for Economic Development		Center for Economic Development Education

Registration Form