WAPA 2008 CME Registration - Down by the River Review
WAPA Member: Yes______ No______ Like to join_______
Address: __________________________________________________________________
City: _____________________________ State:_________ Zip:______________________
Email:____________________________________________________________________
Social Security / AAPA / NCCPA # _________________________________________
(list one for CME purposes)
Guest Name: _____________________________________________________________
Attending the : Wine & Cheese Party Y____N____ # of people_____________
WAPA Banquet Y____N____ # of people_____________
Picnic / Golf Y____N____ # of people _____________
FEES: Postmarked by6/15/08 Postmarked after 6/15/08 Amount Enclosed
WAPA Member $250.00 $275.00 _______________
Non- Member PA $330.00 $355.00 _______________
Guest (inc. all activities) $ 50.00 $ 50.00 _______________
Picnic $8.00 $10.00 _______________
WAPA Banquet/per person $25.00 $25.00 _______________
TOTAL : _________________
PAYMENT
VISA #____________________________ or MASTERCARD #_____________________________
exp. date _____________________ exp. date ___________________________
Name_____________________________ Name____________________________________
*Make Check payable to: WAPA (tax ID# 830266205)
Mail payment to: Val Goen, 1522 East A Street, Casper, Wyoming 82601
*----------press print button to print off registration form------*
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