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Registration Form - Phoenix Chapter

NAIC PHOENIX CHAPTER -- EVENT REGISTRATION FORM

REGISTRATION INSTRUCTIONS

YOU MUST PRINT OUT THIS FORM
Complete it with information pertaining to the event you wish to attend
Make your check payable to: Phoenix Chapter
Mail the form, with the check to: Phoenix Chapter
12821 N. 30th St.
Phoenix, AZ 85032

NOTE: Class size is limited. Advance Registration Required

Supply a SASE or an E-mail address if confirmation is requested.

Name of event : __________________________________________________

Date of event : ________________________

Fees enclosed : ________________________

Name: _________________________________________________________

Address: _______________________________________________________

City/State/Zip: ___________________________________________________

Phone: (___)_______________ (day) (___)__________________ (evening)

E-mail Address: _____________________________________ (If any)

Club Name: ________________________________________ (If any)

NAIC Member #: ___________________________________ (If any)

Confirmation Requested: Yes ____ No ____

Please supply the Names, Addresses, Phone numbers and E-mail addresses for any additional persons registering on this form.

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