Event Registration

Name: _______________________________________________        Event Name: ____________________________________

Chapter Name: ________________________________________        Event Date: _____________________________________

Address: ______________________________________________      Phone Number : ( ______ ) _________________________

               ______________________________________________

Form of Payment: _______________________________________     Number of Tickets Required: _______________________ 

Credit Card #: __________________________________________    Expiry: _____ / ______

                                   (We accept Visa and Mastercard)

Names of Attendees (if paying for more than one ticket):

Signature: ________________________________________________

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