What do you want on your Conference Badge? Name: Affiliation: How can we contact you? (please provide both) Email: Phone: How will your registration fee ($75) be paid? VISA Mastercard credit card number: expiration date: name on card: Which hotel have YOU made reservations with? Garden Plaza Hampton Inn Comfort Inn Other: Important Info arrive (date and time): depart (date and time): Will attend reception on 10/6 Will attend banquet on 10/7 Do you have any special dietary requirements?
What do you want on your Conference Badge? Name: Affiliation:
How can we contact you? (please provide both) Email: Phone:
How will your registration fee ($75) be paid? VISA Mastercard credit card number: expiration date: name on card:
Which hotel have YOU made reservations with? Garden Plaza Hampton Inn Comfort Inn Other:
Important Info arrive (date and time): depart (date and time): Will attend reception on 10/6 Will attend banquet on 10/7
Do you have any special dietary requirements?