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Contact and billing (* fields required) |
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| * Ordered by (name as it appears on credit card, e.g. John Q.
Smith) Membership Number |
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| * Mailing address (e.g. 123 Main or P.O. Box 9) |
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| * City * State/Province * ZIP/postal code |
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| Work phone
(area code & number) |
* Home phone (area code & number) |
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| * Email address (required for verification!) |
Prefer
confirmation by Email Postcard |
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| * Credit card (required for web orders!)
VISA MasterCard * Card number |
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Registrations ( * fields required) |
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| Quantity | Type | Rate | Total (US Funds) |
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| * | Adult Registration | $100.00 | $ | ||||||||
| * | Junior (under 12) Registration | $50.00 | $ | ||||||||
| Shipping and
handling: $3.00 will be added for each eight registrations |
$ | ||||||||||
| * TOTAL | $ | ||||||||||
Guest namesFor orders of more than ten guests, submit additional names via email to Kathy Gilliver, convention@spebsqsa.org, or fax 414-654-5552. |
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| Chapter name (e.g. Bay Area Metro) to appear on name badge |
Please check here
if you have a disability and may require accommodation in order to fully participate in
the convention. You will be contacted by a staff member to discuss your specific needs. Yes No |
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| * Ordering guest's name |
Ordering
guest's nickname |
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| Guest name
2 |
Guest nickname
2 |
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| Guest name 3 |
Guest nickname
3 |
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| Guest name 4 |
Guest nickname
4 |
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| Guest name 5 |
Guest nickname
5 |
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| Guest name 6 |
Guest nickname
6 |
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| Guest name 7 |
Guest nickname
7 |
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| Guest name 8 |
Guest nickname
8 |
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| Guest name 9 |
Guest nickname
9 |
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| Guest name 10 |
Guest nickname
10 |
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