Register for Districts III & V

FCLB Districts III & V Meeting Registration
We look forward to seeing you!

Halifax, Nova Scotia
September 8 - 11, 2011



Contact Information Please enter your contact information as you'd like it to appear in the District notebook
Courtesy Title*
Degree (e.g. D.C., M.D., etc.)
Attendee's First Name*
Attendee's Middle Name or Initial
Attendee's Last Name*
Attendee's Suffix

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

City*
State/Province
Zip/Postal Code*
Country

Attendee's Day Phone (123-456-7890)*
Attendee's Fax Number (123-456-7890)
Attendee's E-mail Address*
--The following phone number fields are for FCLB use only and will not be distributed.--
Attendee's Home Phone (123-456-7890)
Attendee's Cell Phone (123-456-7890)
Name Badge Please complete EXACTLY as you would like it to appear on the Attendee's Name Badge

Attendee's Title within board or organization*
Board or Organization Representing*

Travel Information The following information helps both the FCLB and the Hotel 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 dietary or accessibility considerations we should know about?
Please list any guest(s) who will be joining you	-
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

Anything else the FCLB staff should know about?




Registration is $295. You will receive an invoice via e-mail.






* Required