JBS Mast Head

Registration Form

25th Annual
Texas Leadership Forum
Presented by the John Ben Shepperd Public Leadership Institute
January 15 - 16, 2010

Registration is limited to 150 participants, aged 21 and over.

Registration - $250*
Late Registration (after December 15, 2009) - $300
* A limited number of scholarships are available.  Please call for more information.


(* Required)
Prefix *
Mr.
Mrs.
Ms.
Dr.
Name

Date of Birth

Name preferred for name tag

Preferred Address *
Business
Home
Street / PO Box

City

State

Zip

Phone

Fax

Email *
I am interested in joining the Shepperd E-leader (electronic newsletter) mailing list. *
Yes
No
Business Name

Position/Title

In case of emergency, notify:
Name

Phone

Special accommodations are required *
Yes
No
Please provide the following accommodations

Please mail check to:

Texas Leadership Forum,
John Ben Shepperd Public Leadership Institute
c/o University of Texas of the Permian Basin
4901 E. University Blvd.
Odessa, Texas 79762

Or call us at 432-552-2850 to provide credit card payment information.