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NOCERCC Convention 2005 Convention Registration Form Please use one form per person Print this form and send it to the National Office |
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Last Name
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First Name
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Middle Initial |
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Address
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City
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State |
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Zip |
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Phone |
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Fax |
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Diocese/Community
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Check One |
Through December 31st |
After December 31st |
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Full Member 1 person |
q $475 |
q $575 |
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Full Member 2+ persons |
q $375 |
q $475 |
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Sponsoring Member, 1 |
q $475 |
q $575 |
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Sponsoring Member, 2+ |
q $375 |
q $475 |
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Associate Member, 1 |
q $475 |
q $575 |
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Associate Member, 2+ |
q $375 |
q $475 |
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Affiliate Member |
q $350 |
q $450 |
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Non-member |
q $575 |
q $675 |
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Also sign me up for: |
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Fee |
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q Pre-Convention Workshop (Sr. Doris Turek, SSND)
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1/31 |
$75 |
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q New Directors Workshop
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1/29-30 |
$300 |
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Registration fee includes all convention sessions, expo, materials, six meals, and refreshment breaks. Registrations will be confirmed with payment. If you need to cancel, you may request a refund in writing by December 31; we will refund your registration payment less $150, which is considered a non-refundable deposit.
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Registration and Payment Options
Mail this form and check, payable to NOCERCC, for your total payment to NOCERCC National Office.
Fill in credit card information below and mail this form to NOCERCC National Office.
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q VISA
q Master Card q American Express q Discover
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Name on Card
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Credit Card Number
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Expiration date |
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Signature |
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