Workshop Registration Form

Cisco Entrepreneur Institute

Starting a Business 10
June 19, 2013 – September 25, 2013
15 sessions: Every Wednesday evening 6 - 9pm
$ 600

Participant Information

Name:	Home Address:
Company Name:	Home Phone:
Title:	Mobile Phone:
Website:	Work Phone:
Education: Degree & Year	Email:
In which sector do you want to start a business?
Please list any professional associations, groups, clubs, or organizations you belong to:

Preferred Social Networking Site: Click here to choose

Do you have access to an internet connection with a speed of at least 512 Kbps? Choose below.

English Proficiency:

Speaking: Click here to choose	Reading: Click here to choose	Writing: Click here to choose

Payment Details

Workshop Selection	Payment to be made:	Method of Payment:

Signature: ________________________________________ Date: _____________________

To reserve your place, please submit this form by fax or email no later than June 7.

Your registration will be complete upon finalizing the payment at AMIDEAST:

Bazerkan Bldg, 1st floor, Nijmeh Square, Riad El Solh St. Beirut Downtown

Telephone: +961 1 989901 ext: 236

Fax: +961 1 989901 ext: 100

Email: csouaid@amideast.org

Website: www.amideast.org/lebanon