test CAPTASA 2024 Conference Registration Form Contact Name * First Last * Last Profession/Credentials Name for Nametag * Institution/Organization Mailing Address * City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 21, 2024 $300 Early Registration Fee (early registration ends January 5th, 2024) $350 Registration Fee (after January 5th, 2024) 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
