CAPITAL SYMPOSIUMS Registration Form for October 17, 2009

Make payment to “Capital Symposiums”.  Return your completed form to Jill Grassmick, 803 Hook Hill Rd Luray, VA 22835  jgrassmick@aaahawk.com   Five day notice refund policy. DCDHA/Capital Symposiums reserves the right to cancel due to unforeseen circumstances. Capital Symposiums is an Approved Pace Program Provider 8/1/2008 to 7/31/2011      

*PLEASE PRINT*

NAME:__________________________________  License#_______________________

ADDRESS:_______________________________________________________________

CITY, ST, ZIP:____________________________________________________________

Phone #_______________________________(H)_____________________________(C)

E-mail Address:________________________________________________________________

Check which applies:     ྜྷ ADHA member $55        ྜྷ Non-Member $85       ྜྷ Student $20

Make checks payable to:  “Capital Symposiums”.  

Mail to:   Jill Grassmick
               803 Hook Hill Rd
               Luray, VA 22835

QUESTIONS?  
 

For registration info:                       For general info:

Jill Grassmick                    
jgrassmick@aaahawk.com