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                                    Workshop Application

Please print and complete both pages of the application and mail to Reitan Labs.

Indicate which workshop(s) you would like to attend:

Basic Training Workshop for Adults – September 27, 28, 29, 2004

□  Early Registration postmarked on or before June 30, 2004 ...........................  $ 450

□  Standard Registration postmarked July 1 – September 13, 2004 .................  $ 475

□  Late Registration postmarked on or after September 14, 2004 .....................  $ 495

Advanced Master Series Workshop – October 1, 2, 3, 2004

□  Early Registration postmarked on or before June 30, 2004 ...........................  $ 450

□  Standard Registration postmarked July 1 – September 13, 2004 .................  $ 475

□  Late Registration postmarked on or after September 14, 2004 .....................  $ 495

Special Discount Registration

□  Registration for both the Basic Training Workshop for Adults and the Advanced
       Master Series Workshop  postmarked on or before June 30, 2004 ............... $ 800

Textbooks

□  Neuroanatomy and Neuropathology:
       A Clinical Guide for Neuropsychologists..................................................... $ 39.95

□  The Halstead-Reitan Neuropsychological Test Battery:
       Theory and Clinical Interpretation ............................................................... $ 49.95

 Total Amount Due .......................................................  $                     

Please print your name exactly as you want it to appear on your Certificate(s) of Attendance.

Name  _________________________________________________________________________

Address  _______________________________________________________________________

City/State (Province)/ZIP  __________________________________________________________

Work Phone  ____________________________  Home Phone  ___________________________

Fax  _____________________________  Email  _______________________________________

Discipline/Specialty  ______________________________________________________________

Highest Degree/Year/Institution______________________________________________________

□  Check or money order enclosed

□  Charge to my visa/mastercard

Number  ____________________________________ Expiration  _________________________

Signature  ______________________________________________________________________

Mail completed application with payment to:        

Reitan Neuropsychology Lab
POB 66080
Tucson, AZ    85728
USA

Registrants who are paying with a credit card may elect to fax their completed applications to:

Reitan Neuropsychology Labs at 520.577.2940.