Are you an APCO Member?    YES   NO APCO Membership Number

First Name Middle Initial Last Name

Title

Agency

Mailing Address

City   State  Zip

Telephone Email Address

SPECIAL NEEDS? Attendees requiring special assistance should contact the Conference Chairman at 610-344-5084 (or mgroce@chesco.org).
List below anyone who will be attending with you: (Spouse, Guest, Child).

Guest#1

Guest#2

Please check all that apply	Registration Type	On or Before May 1, 2008	After May 1, 2008	Amount Due
	APCO Member Full Conference Registration Monday Training Seminar, Tuesday, and Wednesday sessions	$80.00	$100.00
	Non Member Full Conference Registration Monday Training Seminar, Tuesday, and Wednesday sessions	$130.00	$150.00
	APCO MEMBER Monday Training Seminar Only (Does not include Monday night Exhibits Opening)	Free	Free
	NON-MEMBER Monday Training Seminar (Includes Monday Exhibits Opening)	$50.00	$50.00
	Monday Technical Sessions (Includes Monday Night exhibits opening)	$50.00	$50.00
	Monday Night Exhibits Opening Only	$20.00	$20.00
	One Day Conference Registration - Tuesday	$50.00	$50.00
	One Day Conference Registration-Wednesday	$50.00	$50.00
			Total Amount Due

YES  NO

       I will be paying by check (please print this form and include with your payment)
                    Send checks to:  Berniece Jarbeck, PA APCO Treasurer
                                                Elk County Emergency Services, P. O. Box 448 ,Ridgway, PA 15853

        I will be calling to pay by credit card over the phone
                    Please call Berniece Jarbeck  814-776-4600, Fax 814-772-1697
                    bjarbeck@elkoes.com

         

                 Please send me an invoice

 

                 Please send me a receipt

Please print this form for your records before clicking the Submit button.