1 239 514 3081 mail@icsamail.com

Register by Fax, Mail, E-Mail, Phone

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:  mail@icsamail.com

Name(s):

Address:

City: State: Zip:

Country:

Phone(s)/Fax:

E-mail:

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 mail@icsamail.com.

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
   Double Occupancy  $290  $315     
   Single Occupancy  $345  $370     
         Member Deduction   
         Contribution   
         Total Amount Enclosed   

Double Occupancy

If you have a roommate, please tell us his/her name?

Do you want us to assign you a roommate?  Yes [      ]        No [      ]

Group Info

What is the name of the group you belonged to (for each registrant)?

How long have you been out of the group?

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1 239 514 3081 mail@icsamail.com