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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