ACBNY 2017 Legislative Registration
ACBNY 2017 Legislative Registration
Please fill out the form below to register
Name
Name
First
Last
Address
Address
Street Address
Address Line 2
City
State / Province / Region
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District 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
Postal / Zip Code
Country
United States
Phone
Email
Number of Nights at $84 per night
My Roommates are:
Registration Fee $20 payable by all attendees
Lunch: $22 includes Vegetable soup, Saratoga Chils, Dessert, Soft Drinks, tea or coffee.
Please choose an option for the main course:
Monty Crisco
Turkey BLT
Tuna Croissant
Chicken Ceasar Salad
Grilled Veggie Wrap
Sponsorship, Please enter a value, and THANK YOU!
Total = Rooms * $84 + 20 (Admin) + $22 Lunch + Sponsorship
How would you like to pay?
Online by Paypal
By Check
Please enter your total to pay online
$
Dollars
.
Cents
Thank you, please make your check payable to ACBNY and send to:
Mike Golfo
c/o ACBNY
104 Tilrose Ave.
Malverne, NY 11565-2024
Questions? Please call Mike Godino, 516-887-1336 or email
mikeg125@optonline.net