2008 W.I.S.E. RESERVATION FORM

The _______________________________________________ school/school system is planning to send students to the Women in Science and Engineering (W.I.S.E.) Career Day at Salem State College on March 11, 2008.

Please check one box:

________ I will serve as the system liaison for the W.I.S.E program and may be reached at:

School Street Address:

School Town, State, Zip

Phone:

E-Mail Address: (required)

_______ I am designating the following person to serve as system liaison for the W.I.S.E program. This person will receive all future correspondence.

Name:

School:

School Street Address:

School Town, State, and Zip

Phone:

E-mail Address: (required)

Your name: __________________________________, CPMSIE System Representative

Date: _______________________________________

To reserve places for your system’s students please return this by January 4, 2008. This form may be mailed to the address below or faxed to 978-542-7215.

Jim Terlizzi

SB117A

Salem State College

352 Lafayette Street

Salem, MA 01970

jterlizzi@salemstate.edu