2017 Print and Fax Workshop Registration Form

 2017 FLA ANNUAL WORKSHOP & SEMINAR REGISTRATION FORM

Please complete and return to:

Florida Lawyers Assistance, Inc.
2335 East Atlantic Blvd, Suite 410
Pompano Beach, Florida 33062
Tel: (954) 566-9040
Fax:(954) 568-0803
Email: mail@fla-lap.org

 

Name:                                                                                                                                                                                         
(Last)                                                                               (First)

Name as it should appear on badge:                                                                                                                                  

Address:                                                                                                                                                                                                      
(Street)
                                                                                                                                                                                   
(City)                                                                               (State)                        (Zip)

Telephone:                                                                    

E-mail:                                                                           

Guest(s):                                                                                                                                                                                                     
(Last)                                                                               (First)

Guest Name(s) as they should appear on badge:                                                                                                                             

Are you interested in room sharing?   [   ] Yes    [   ] No

Please check the following that apply:

Early registration fees (by July 1, 2017) @ $150.00                                                                                     $                                 

Registration fees (after July 1, 2016) @ $180.00                                                                                      $                                 

Guest fees @ $75.00                                                                                                                                          $                                 

[   ] I have qualified for a scholarship and will be paying $75.00

for the cost of food.                                                                                                                                           $                                 

[  ] I have qualified for a full scholarship

Contribution to be used toward Workshop scholarships                                                                         $                                 

Tax deductible donation to the Hagan-Kilby Fund

for indigent attorney treatment                                                                                                                   $                                 

FLA monitors, please deduct $25.00                                                                                                         $                                 

TOTAL   $                                 

                  [ ] I HAVE PAID THE ABOVE AMOUNT ONLINE THROUGH THE FLA/PAYPAL WEB SITE

                                                                        (http://www.fla-lap.org/fla-payment)

Registration includes:       Workshop Dinner and Breakfast

Guest Fee includes:          Dinner and Breakfast

No refunds after 7/14/17