Name of Training Session ___________________

Payment is for _____ attendees

Full Name (Attendee 1)________________________________________
Full Name (Attendee 2)________________________________________
Full Name (Attendee 3)________________________________________
Full Name (Attendee 4)________________________________________
Full Name (Attendee 5)________________________________________
Firm / Organization ______________________________

Do you work for a State Bar funded direct service program?______________

Firm / Organization Address ______________________
__________________________________________________
City _________________ State _____ Zip ___________

Phone Number __________________
Fax Number ____________________
Email Address _________________
Web Address ___________________

Amount of Payment ____________
MasterCard / Visa (please circle one)
Name on Card ____________________________________
Card Number _____________________________________
Expiration Date _______________________
Signature _____________________________

In addition to the payment for my training session I want to donate $_________ to The Impact Fund. Please charge my donation to The Impact Fund to my credit card.

Thank you for supporting The Impact Fund. If you chose to give a donation in addition to the payment for your training session, then a confirmation letter
acknowledging your donation will be mailed to you.