2012 School Violence Conference Registration Form

Friday, October 12, 2012
9:30 a.m. – 1 p.m.
St. John’s University, Queens campus
Bent Hall, Room 277A/B

Name:

Phone Number:

()-

Billing Address:

City:

State:

Zip:

E-mail:

Choose one:

WE DO NOT ACCEPT PAYMENT ONLINE AT THIS TIME:

We accept payments by check, money order or credit card.
Checks: Please make check payable to: St. John's University.
For Continuing Education credits, please send a separate payment of $10.

Mail, payment to:
Rafael A. Javier, Ph.D., ABPP
Office of Postgraduate Professional Development Programs
St. John's University
Marillac Hall, Room 402
8000 Utopia Parkway
Queens, NY 11439
Tel (718) 990-5460
Fax (718) 990-5485
Initiatives@stjohns.edu

To pay by credit card, please call (718) 990-1972
AMEX, VISA, MASTERCARD ACCEPTED
Registration will not be completed until payment is received