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