Teva Learning Center - Classroom Teachers Seminar Registration

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Please fill out the below information accurately.

* - Designates a required field

Participant Information

Please fill out the participant information below. This form is for US Residents only. Please contact the Teva Learning Center for foreign registration.

* First Name
* Last Name
School
* Address
Address (cont)
* City
* State (abbreviation)
* Zipcode
* Email Address
Phone Number (XXX-XXX-XXXX)

Billing Information

Please fill out the billing information below. This is the address that you would like the receipt returned to.

Check here if participant information is the same as the billing information

* First Name
* Last Name
School
* Address
Address (cont)
* City
* State (abbreviation)
* Zipcode

Payment

* Payment Type	Pay by Credit Card Pay by check. Please send checks to the Teva Learning Center 307 7th Ave. Suite 900, New York, NY 10001
* Name on the Credit Card
* Type of Credit Card	Visa Mastercard
* Credit Card Number
* Expiration Date (mm/yyyy)	/
* Zip Code on Credit Card
* Payment Amount	$130.00 ($30 is non-refundable)