Mark Lissick/Wildlight Nature Photography and Workshops-Workshop Registration

REGISTRATION

Please select the workshop/photo adventure(s) you wish to attend:

[You may select more than one workshop by simply holding down the control button and clicking on your desired choices]

Workshops & Adventures:

(Dominica Note: Full balance is due upon registration.)

Please provide the following registration information:

First Name

Full Middle Name (For Alaska Bald Eagle Trip Only)

Last Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Date of Birth (For Alaska Bald Eagle Trip Only)

Passport Number

Work Phone

Home Phone

Cell Phone

E-mail

Physical Limitations

Dietary Requirements

NANPA Membership Number (if applicable): Expiration Date: Month: Year:

**You must be an active member in NANPA at the time of registration in order to receive your discount.**

Payment:

Pay by check:

[Your registration will be held for a maximum of seven days for your check to arrive by mail. Registration will not be final until check has cleared.]

Credit Card Type:

Credit Card Number:

Expiration Date: Month: Year:

CCV #: (3 digit code on the back of the card):

Amount To Be Billed:

NOTE: Where applicable, your deposit as part of the workshop fee guarantees your registration pending payment of the final balance as stated under the registration terms for each workshop. Should you need to cancel you will receive a refund less a processing fee as stated in the registration terms for each workshop.

Automatic Charge?
	Check here to authorize Mark Lissick/Wildlight Nature Photography to automatically charge the next applicable payment/balance to the same credit card used for the deposit payment. Charges will not be applied until the time that payment is due as indicated in the registration terms for each workshop.

	Check here if you would prefer to have the full workshop fee charged now. Note: If you are registering less than 120 days prior to a workshop we will automatically charge the full course fee.



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