Register for District II

Wednesday, May 16, 2012

Register

FCLB District II Meeting Registration
We look forward to seeing you!

Fort Walton Beach, Florida
October 13-16, 2011

Contact Information Please enter attendee's contact information as you'd like it to appear in the meeting notebook.
Courtesy Title (Mr., Ms., Dr.)

Attendee's First Name

Attendee's Middle Name

Attendee's Last Name

Suffix (Jr., Sr., etc.)

Degree(s) (D.C., M.D., etc.)

Attendee's Street Address - up to 2 lines
Please do not include organization name in street address

City

State or Province

Zip or Postal Code

Country

Attendee's Day Phone (123-456-7890)

Attendee's Fax Number

Attendee's E-mail Address
-The following phone numbers are for FCLB use only and will not be distributed-
Attendee's Home Phone

Attendee's Cell Phone
Please enter the information below EXACTLY as you'd like it to appear on the Attendee's Name Badge.
Title within Board or Organization (President, Secretary, etc.)

Board or Organization
Travel Information The following information helps the FCLB plan for you. Please enter as much as you know at this time.
Hotel Arrival Date

Approximate Arrival Time

Hotel Departure Date

Approximate Departure Time

Special Accomodations	Are there any accessibility considerations we should know about?

Please list any guests who will be joining you
Other Contacts If you are completing this registration form on behalf of someone else, please provide the following contact information.
Your Name

Your Phone Number

Your E-mail Address

Other Notes or Comments

Registration is $295 You will receive an invoice via e-mail within the next five business days.

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Web site questions? E-mail Kelly! - Questions about the meeting? E-mail Julie!

Fees

Registration	$295
Cancellation	$ 50