<p> Stan A. Huber Consultants, Inc. Radiation Safety & Management Seminar Sign-Up Sheet 200 North Cedar Road – New Lenox, Illinois 60451 Phone: (800) 383-0468 – Fax: (815) 485-4433</p><p>**Please email the completed form to us at [email protected]**</p><p>Name & Title of Attendee: Name & Street Address of Company:</p><p>Attendee Email Address:</p><p>Company Phone Number: Company Fax Number:</p><p>Please  Seminar Location:</p><p>February 17 - 19, 2016 New Lenox, Illinois June 1 – 3, 2016 New Lenox, Illinois</p><p>Payment Information: Registration fee is $650.00 per person (please complete one form for each attendee)</p><p>VISA Number: Mastercard Number:</p><p>Expiration Date: / Expiration Date: / </p><p>Check Number: Acknowledgement Letter Sent On:</p><p>Will Send Check By: TO BE FILLED OUT BY SAHCI PERSONNEL ONLY Additional Information or Comments:</p>