Agency: ______________________________________________________

Address:  ______________________________________________________

City:    __________________    State:  _____    Zip:  _______________

Telephone:    _________________    Fax:  __________________________

E-mail:  ______________________________________________________

Cellular Phone:  _______________________________________________

 _____    Check or Money Order for $495 enclosed

_____    Will pay at Registration - $495

__________________________ Purchase Order Number - $550

______________________________# Visa/MC/Amex  ($495)  Exp Date  ___________

Make all checks, money orders or purchase orders payable to International Association of Undercover Officers
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