Event Registration

Use this form to register and pay with a credit card or check. If you choose to pay by check, the information you enter below will be added to our records, but your reservation will not be confirmed until your payment is received.

You are registering for:

HATS & HEARTS FOR HAITI WITH NICOLE SHELLEY MODELS
Wed, Feb 24, 2010
6:30 PM - 9:00 PM

This event will take place at:

Sci Sci Restaurant and Lounge
1053 SE 1st Avenue
Miami, FL 33131

Event Costs:

Please indicate your membership level:

	Non- Member: $20.00
	Chapter Member: $20.00

Personal Information:

Please enter your name as you wish it to appear on your badge. To include your certification, enter it after your last name.
Example: Smith, CPPB

First Name:
Last Name:
E-mail Address:
Agency:
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Washington DC West Virginia Wisconsin Wyoming
Zip Code:
Phone Number:	-   -

Payment Information

You may pay online with a credit card, or indicate that you will pay by check.

	Payment by check
	Payment by PayPal (pay with credit card)