Mississippi e-learning for Educators- INVOICE

INVOICE
Facilitator Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Class Taught
Class Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Class End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Session
Number of Participants
MPB will pay me the following amount for teaching this course.
I agree that the above information is accurate. I am digitally signing this form by typing in my full name.
Signature
Should be Empty: