Fax/Mail Registration Form: Colorado Former Member Workshop – July 29-31, 2016
Complete the form below and fax, e-mail, or mail it to: ICSA, PO Box 2265, Bonita Springs, FL 34133. Fax: 1-305-393-8193. E-Mail: email@example.com
City: State: Zip:
Payment: [ ] Check [ ] Visa [ ] Mastercard
CC no: CC exp:
Use the table below to calculate the amount due. All rates are per person and include meals (Friday dinner through Sunday lunch) and Friday and Saturday accommodations. If you have questions, contact ICSA at (239)-514-3081 or firstname.lastname@example.org.
ICSA Members may deduct $25. Non-members receive an introductory Web membership with registration fee.
|No. People||Status||Register By 4/1/16||Register After 4/1/16||Adjustments||Amount|
|Total Amount Enclosed|
If you have a roommate, please tell us his/her name?
Do you want us to assign you a roommate? Yes [ ] No [ ]
What is the name of the group you belonged to (for each registrant)?
How long have you been out of the group?