2013 APSE Conference Registration ONE DAY REGISTRATION FORM

APSE 2013 National Conference Registration One Day Registration Form First Name Last Name_____________________________...

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APSE 2013 National Conference Registration One Day Registration Form

First Name

Last Name_____________________________________________

Job Title

Company Name

Mailing Address City

_State

Telephone Number

Zip ________________________________________________________________________

E-mail

_________________________________________________

Please answer the questions below:

___I will attend on Tuesday, June 25, 2013 ONLY ___ I will attend on Wednesday, June 26, 2013 ONLY ___I will attend the Awards Luncheon on Wednesday, June 25th included in my registration fee. ___Vegetarian Meal requested ___I will attend the 25th Anniversary Reception on Tuesday, June 25 from 5pm to 7:30pm APSE National Conference Registration Fees 2013

ONE DAY RATES Payment due by May 24

APSE MEMBER

Payment Information Make Check payable to APSE

Check #_______________

Amount: _______________________ Credit Card #: _______________________________________________________________________

Tuesday, June 25, 2013

$160

Expiration Date:____________________________________________________________________

Wednesday, June 26, 2013

$160

Security Code:_____________________________________________________________________

$80

Name on Card: _____________________________________________________________________

Thursday, June 27, 2013 (1/2 Day)

Billing Address: ___________________________________________________________________

NON-MEMBER

City/State/Zip:____________________________________________________________________

Tuesday, June 25, 2013

$220

Wednesday, June 26, 2013

$220

Signature: _________________________________________________________________________

Thursday, June 27, 2013 (1/2 Day)

$110

Email Address of where you want the Sales Receipt Sent:

APSE Membership TOTAL Amount Due:

$105.00

_______________________________________________________________________________________

Mail Check to: 416 Hungerford Dr., Ste. 418, Rockville, MD 20850

Please Email or FAX the Registration Form to [email protected] or 301-279-0075 Payment is due before or by May 24, 2013