REGION III 2019 RTC

REGION III 2019 RTC

PRE-REGISTRATION FORM

BLACKS IN GOVERNMENT (BIG) REGION III

FOR OFFICIAL USE ONLY 2 0

REGIONAL TRAINING CONFERENCE

October 18 ? 19, 2019

THEME: " Maximizing Performance Through Excellence"

INSTRUCTIONS: Please return completed form with payment ? POST MARKED BY September 30, 2019 to: DIANA S. DAVIS, BIG REGION III RTC, 6439 Oak View Drive, Harrisburg, PA 17112 (type or print all information). Registration will NOT be processed without proper method of payment ($75.00 Fee). Luncheon Only ($40.00). EVERY REGISTRANT MUST HAVE A REGISTRATION FORM. For additional registrations, please photocopy and complete this form. For further information, please contact: Diana S. Davis 717-319-4814 Cell / Linda Bouie 609 405-3990

Mailing Address for Confirmation Letter

Billing Address

Name (please print) Address: City/State/Zip: Contact Telephone: Contact Email Address:

Employer/Agency Trng/Support Office Name: Trng/Support Office POC & Telephone: Trng/Support Office Address: City/State/Zip Emergency Contact Information

Full Name:

Relationship:

Home Telephone:

Work Telephone:

Please identify medical conditions(s) which may require emergency treatment: _______________________________________________________

Check if you require information to secure local Americans with Disability Act (ADA) service/device/equipment. * Specify service information needed **Region III, Blacks In Government is not responsible for obtaining or procuring special ADA services / devices/equipment for conference attendees

Registration Fee of $75.00 includes Training Sessions and Luncheon.

Pre-Registration Fees Member

Non Member

Host Hotel

Four Points by Sheraton Philadelphia Northeast 9461 Roosevelt Boulevard Philadelphia, PA 19114 1-215-671-9600

[ Registration Fees: ( $75.00) Luncheon Only ( $40.00)]

CHAPTER:

NEAgape

METHOD OF PAYMENT

For Reservations Call 1-215-671-9600

Check /Money order

Cash

Cash App $bigregion3

*A registratrion form must be attached for each conference attendee. A form with multiple names will be retruned to sender.

REFUND AND CANCELLATION POLICY No refunds or cancellations will be honored. Confirmed registrants who do not show up for the conference are liable for the entire registration fee.

Date Received:

Date Approved:

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