NCPAA Conference 2004 Registration Form

Name:___________________________________________________________________________________

Title:__________________________________________________________________________________

Agency or Organization:_________________________________________________________________

Mailing Address:________________________________________________________________________

              _________________________________________________________

City:__________________________State:____________________________Zip:___________________

Phone:_______________________Fax:_______________________E-Mail:_________________________

Registrant’s Shirt Size (Circle one):    M   L   XL  XXL   XXXL

Registration Fee:

 Early Registration (Prior to February 29, 2004)                  $150.00

 Normal Registration ( March 1, 2004 – March 31, 2004)            $185.00

 Late Registration (April 1, 2004 and walkups)                    $225.00

 Spouse Attendance at Meal ($50.00 each)                          _______

 Exhibit Space: Alumni/Non-Profit ($100)  – Table Only            _______

 Private/For Profit ($600)  Table & 2 registrations               _______

 Total Registration:                                             $_______