2013 FLA Workshop eRegistration Form

First Name:

Last Name:

Email:

Phone:

Address:

City:

State:
Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Registration Fee ($150 before July 10; $170 after 7/10)

Your Badge Name

Number of Guests (in addition to you) @$75/guest
1
2
3
4

Guest Badge Names

Voluntary Contribution to the Hagan-Kilby Fund in the following amount:

Voluntary Contribution to the workshop scholarship fund in the following amount:

I have been qualified by FLA for a scholarship at $75
Yes
No

Are you an FLA monitor? If yes, please deduct $25 from your registration fee
Yes
No

Total Amount Due:

I HAVE PAID THE TOTAL AMOUNT DUE THROUGH THE FLA PAYPAL OPTION (but understand I still must submit this registration form)
Yes
No

(Only click the Submit Button Once)