A Circle of Ten, Inc.

Network for Collaboration

Mission: To empower leaders and foster healthy collaborations to improve quality of life.
Vision: A Circle of Ten is a catalyst and neutral intermediary agency that builds capacity of
leaders and communities, multiplies services, and increases funding in rural Texas.
Phone (903) 541-0013
205 E. Commerce #205
circleof10@circleof10.org
Fax (888) 214-5210
Jacksonville, TX 75766
www.virtual-village.org

Workshop Application
Space is Limited
Register Early
Part I Workshop Dates____________________ Part II Workshop Dates_____________________
Use ONE registration form for all participants from your agency. Limit THREE attending per agency, per class.
Individual participant preliminary interviews are required. A Circle of Ten professionals will call and schedule a 20-minute
interview. This allows Circle of Ten to tailor the workshop to meet the needs of each individual and agency. All
applications must be submitted to the Workshop Committee for approval.

AGENCY NAME __________________________________________________________________

Address_________________________________________________________________________
City_________________________State________Zip_____________County__________________
Phone _(_________)_______________________________________Ext._____________________
Fax_(_________)____________________________Email_________________________________
INDIVIDUALS REGISTERED:

Indicate best time of day to call for interview.

1) Name ____________________________Title___________________ Time to call___________

Phone_____________________Ext.____Fax_________________Email______________________
2) Name ___________________________Title__________________ _ Time to call___________
Phone_____________________Ext.____Fax_________________Email______________________
3) Name ___________________________Title____________________ Time to call___________
Phone_____________________Ext.____Fax_________________Email______________________
WORKSHOP COST: In Edom, TX - $ 800 per participant, per workshop AMOUNT DUE $________
Other Locations - $1,000 per participant, per workshop
Actual per participant cost ($2,000) subsidized by foundations, corporations, banks, individuals and others to lower registration fees.

Method of Payment - Check One: ____Check enclosed

____Purchase Order # _____________

Date to be mailed:________________

___Visa ___ MasterCard Expiration date: ___/___/___

Credit Card Account #__ __ __ __ -__ __ __ __-__ __ __ __-__ __ __ __

Name as it appears on credit card: _____________________ Signature _______________________
Registration confirmed upon receipt of this form & check, purchase order number, or credit card approval.
Cancellation and Transfer Policy - 22+ days, Full refund less $200 processing fee. 14 21 days-Tuition refunded less 50%
processing. Transfer toward future date with 14 days notice-$50 processing fee. Less than 14 days-Fee forfeited. ALL requests
must be made by letter or fax.
Photo/Citation Consent: The undersigned hereby authorizes A Circle of Ten, Inc., its employees, authorized agents, affiliates or
representatives to: photograph, video/audio tape, use quotes and interviews in print and web based media.
Please check all that apply: Photo: __No Web ___No Paper ___No Photo

Citation: __No Web ___No Paper ___No Citation

Signature for commitment to attend date(s) listed above:

Signature _______________________________

Date________________

Office Use Only: Date_____________ Participants ____1 ____2 ____3

Confirmed_______________________ Sent by_______ Date____________
Copyright 1996 Holdway & Associates

Amount Received $_______ Date Received____________

All Rights Reserved

Revised February, 2013