test – Captasa

Contact Name *

First

Last *

Last

Profession/Credentials

Name for Nametag *

Institution/Organization

Mailing Address *

City *

State *

Zip *

Phone

Fax

Email *

Please list any special needs you may have (dietary, etc.):

I will attend

In Person

Online

• Cost of Banquet NOT included in registration fee.
• No one day, group rate or scholarships

NO REFUNDS AFTER JANUARY 14, 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.

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