Due April 9, 2004

Check one:

• Trained Mediator
  
• Non-Mediator
  

  Name: _____________________________________________________________________

  Title: _____________________________________________________________________

  Organization: _______________________________________________________________

  Address: ___________________________________________________________________

  City/State/Zip: _____________________________________________________________

  Phone: ____________________________________________

  Fax: _________________________________________________

  Email: ________________________________________________

  
  
  
  

  Please provide (or attach) a brief description of your background and experience in mediation/aging/guardianship.

  
  
  
  
  
  

  If you have any special accommodation or dietary needs, please list below.

  
  
  
  
  
  

  $450 fee enclosed (rec'd by 4/9/04 deadline)

  $500 fee enclosed (rec'd after 4/9/04 deadline)

  
  
  
  
  Please mail form and payment (payable to PeaceTalks) to:
  

  PeaceTalks
  840 Starwick
  Ann Arbor, MI 48105