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Wisconsin § 106 Submittal Process Registration Form

This is the registration form for the New Wisconsin § 106 Process half-day training programs conducted by Chip Brown, Government Assistance and Training Specialist, Division of Historic Preservation, Wisconsin Historical Society.

Please provide the following information, as applicable:

Number of Persons Registering with this Form: _______________

Name(s) of Participant(s): ___________________________________________________
___________________________________________________

Business/Agency Name: ___________________________________________________

Mailing Address: ___________________________________________________
___________________________________________________

Title and Date of Training: _______________________________

Cost of training is $35.00 per participant.

Method of Payment:

Checks: Payable to: Wisconsin Historical Society

Credit Cards: Visa  or MasterCard (circle one)

Account #:___________________________________________
Expiration date: _______________________________________
Signature: ____________________________________________

Name of card-holder, as it appears on the card:
____________________________________________________

Credit card billing address, if different from registrant address above: ____________________________________________________
____________________________________________________

Total enclosed: ____________

Please mail this form with your payment to:

Chip Brown
Wisconsin Historical Society
Division on Historic Preservation
816 State Street
Madison, WI 53706

If there are any questions about this program, please contact Chip Brown. Thank you very much for your interest in historic preservation.


 

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