First Name*
 Middle
 Last Name*
 Professional Designation(s)
(AICP, PE, ASLA, etc.)
Agency/Firm
Shipping Address:
Address*
City*
 State*
 ZIP/Postal Code*
Phone:
Email:
Include FL Sales Tax?
Tax Exempt ID
NUMBER of SETS of Course Materials @ $50.00 each]: $
NUMBER of SETS of Course Materials (Discounted Member price) @ $35.00 each: $
POSTAGE & HANDLING ($4.00 per set):
6.5 % FLORIDA SALES TAX: $
TOTAL ORDER (CHECK OR MONEY ORDER**): $***
** Checks should be made out to “Palm Beach County Planning Congress, Inc.” & mailed with this form to the address below. ***Electronic payments by cash, credit or debit card can be made via the Pay Pal Link on the Planning Congress website at www.pbcplanningcongress.org, If Pay Pal is used, please fax this form to Frank Palen at 561-655-3775.
FLORIDA BAR MEMBER? Yes No
(Approved by the Florida Bar for 4 hours CLE in Ethics)

AICP MEMBER? Yes No
(Request for American Institute of Certified Planners CM Credit Applied For & Approval Pending)		 MAIL CHECKS TO:
Palm Beach County Planning Congress, Inc
Post Office Box 1371
West Palm Beach, Florida 33402
Questions: Call Frank Palen at 651-655-0620