registration form Registration Form Name First Last TITLE ORGANIZATON/BUSINESS Address Address City State ZIP / Postal Code Phone(Day)FAX Phone(Mobile)Email DO YOU NEED ANY ACCOMMODATIONS? FOR INFORMATION Wheels/Mobility Access Wheels/Mobility Access Assisted Listening/Sign Interpreter Braille/Large Print Personal Assistant/(fee cost of meal ONLY) Other Untitled DISCOUNT CONVENTION PACKAGEPlease Select OneEarly $200.00On-Site $225.00MEAL FUNCTION TICKETSThursday, October 13, 2022 Price: $70.00 Quantity: ONE-DAY REGISTRATIONPlease Select OneThursday $100.00Friday $100.00MEAL FUNCTION TICKETSFriday, October 14, 2022 Price: $70.00 Quantity: Virtual Registration:Please Select OneOne Day $50.00Two Day $75.00Payment TOTAL ENCLOSED for Registration Fees and meal Tickets Payment TOTAL ENCLOSED for Registration Fees and meal Tickets CHECK OR MONEY ORDER ENCLOSED (MADE PAYABLE TO NEW JERSEY BLACK ISSUES CONVENTION) Payment MethodCredit NumberCard Details Cardholder Name
