Program   

            EOC                UB   

            McNair            UB M/S   

            ETS                 VUB   

            SSS

 Institution Name

Contact Name

Contact Number

E-Mail

Shipping Address (for TRiO day shirts)

Address    City     State    Zip

Billing Address (for invoicing)

Check if billing address is same as shipping                           

Address    City     State    Zip

Number of Registrations

T-Shirts (indicate amount needed for each size)

Small    Medium    Large    XL    2XL    3XL    4XL

SPECIAL ACCOMMODATIONS REQUESTED (Requests must be received at least ten days
prior to the event). Please give a brief description of the accommodation requested (special seating, special assistance, etc.).

Choose one of the following payment methods for the workshop:

Purchase Order Check

Please provide the following information:

Check or purchase order should be made payable to ODSA.

Submit payment to: Tony Lehrling

Attention: Tony Lehrling-ODSA Treasurer

Southeastern Oklahoma State University
Upward Bound Math/Science
1405 N. 4th PMB 4222
Durant, OK. 74701
(ODSA FEI# 73-1086249)