Registration deadline is March 14,
2010, 11:59pm CST.
After that date a $45 late fee will be charged. NO EXCEPTIONS! |
PERSONAL INFORMATION: |
| The way you enter your name is how it will be printed on your name tag. |
| First
Name: |
|
| Last
Name: |
|
| University: |
|
| Address: |
|
| City: |
|
| State: |
|
| Zip: |
|
| Cell Phone: |
|
| Email: |
|
MEMBERSHIP INFORMATION: |
Membership:
Check all that apply |
Pi Sigma Epsilon
Mu Kappa Tau
PSE Life Member |
Membership Type: |
|
| Year in School: |
|
| Expected Graduation Date: |
|
How many National Conventions
have you attended: |
|
Date you will be arriving
for convention: |
|
Date you will be leaving
convention: |
|
SPECIAL REQUESTS: |
Vegetarian
Meals: |
Yes No |
I
am planning to compete in the Pro-Am Sell-a-Thon |
You must register
online to participate |
| I am planning to attend
the Certified Chapter Officer Program |
Yes No
Position to be trained
|
EMERGENCY INFORMATION: Must be completed |
| Emergency
Contact: |
|
| Emergency
Contact Phone: |
|
| Medical
Condition(s): |
|
List any medications
you are allergic to: |
|
PAYMENT INFORMATION: |
Payment will be made with a chapter check or chapter credit
card: |
Chapter checks must be received by March 12, 2010 to avoid late registration fees. |
| Name
on Card |
|
| Credit Card: |
Visa
Mastercard
American Express |
| Credit Card
Number: |
|
| Card
Expiration: |
|
CVV2/CVC2/CID
(credit card security code) |
Location on card |
REGISTRATION FEES:
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