National External Diploma Program Council

National External Diploma Program Council

NEDPC Conference Providence, RI

October14-16, 2012

CONFERENCE REGISTRATION FORM

Late Registration Fee of $15 Must Be paid After October 1, 2012

PARTICIPANT INFORMATION: (Please print) One form per registrant

Last Name______First Name______

Title______

Agency______

Street Address ( ) home) ( ) work______

City ______State______Zip ______

Phone (home)______(work)______(c) ______

Email Address______

CONFERENCE FEES

______Current Member $195.00 ______Non-Member $215.00

______NEDPC Membership (Check one)

______Advisor/Assessor $15.00 ______Administrator $30.00

Late Registration Fee (After October 1, 2012) $15.00

Grand Total Enclosed $______

PAYMENT OPTIONS:

A check or PO from an agency must be followed up with confirmation to the treasurer with the names of those attending.

MAIL FORM AND PAYMENT TO: QUESTIONS/PRESENTATION CONTACT:

Myra Thistle, Treasurer Sharon Muldowney Bette Huckabee

1 Cornfield Lane Middletown Adult Education 944 Laurel Ave.

Madison, CT 6443 398 Main St. Bridgeport, CT 06604

Middletown, CT 06457 (203)338-0503

(860)343-5597

NO REFUNDS WILL BE GIVEN