test CAPTASA 2024 Conference Registration Form Contact Name * First Last * Last Profession/Credentials Name for Nametag * Institution/Organization Mailing Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Phone Fax Email * Please list any special needs you may have (dietary, etc.): I will attend * In Person Online Payment Information • Cost of Banquet NOT included in registration fee. • No one day, group rate or scholarships NO REFUNDS AFTER JANUARY 14, 2023 $250 Early Registration Fee (early registration ends January 5th, 2023) $300 Registration Fee (after January 5th, 2023) I plan to attend the banquet Friday night (cost $35) * Yes No # of guests @ $35 per ticket - Do not include yourself in this count. * # of Handouts @ $35 per set * MUST PRE-ORDER BY JANUARY 17 - NOT AVAILABLE FOR PURCHASE AT CONFERENCE - Handouts will be available online @ www.captasa.org for no charge. FOR EXPRESS REGISTRATION AT THE CONFERENCE: Print your receipt and bring it with you when you register in Lexington. Total If you are human, leave this field blank. Pay Now
