PSMLA Technology Workshop
Registration Form
July 5-8, 2005

Name _________________________________ Name of school ________________________________

Home address ______________________________ School address ____________________________

__________________________________ _______________________________

__________________________________ _______________________________

E-mail __________________________________

Home phone __________________________________ School phone __________________________________

Language(s) taught __________________________________ Position __________________________________

Circle one: PSMLA member ($50) Non-member ($85) [includes PSMLA 2005 membership!!]

Please make check payable to PSMLA and send it with this form to Devin Browne, 4263 Andover Terrace, Pittsburgh, PA 15213.

Deadline to enroll is Friday, June 24, 2005. Enrollment space is limited. Sufficient enrollment will be required. If it is necessary to cancl, notice of cancellation will be by Monday, June 22, 2005.