___ Yes, I would like to prepare to become licensed. 

Please send a set of course materials to the address below and reserve 
a space in my name to attend the review week, a check for $850.00 (payable to C.I.B.A.) is attached.

Name: __________________________________________________________________________ 

Title: _________________________________ Company: ______________________________

Address(1): ____________________________________ Address(2): _______________________

City/State/Zip: ________________________________ Telephone: ________________________

Fax: _________________________ E-mail: ______________________________________

Please mail or fax your registration form so we receive it by January 23, 2012.
If you fax, your check must be received by us by January 23, 2012.