First Name*     

Last Name*     

Title                 

Address 1*      

Address 2        

City*                

State/Province*   Zip/Postal Code* 

Representing  

Day Phone*     

Home Phone    

Fax                   

Email                

Guest 1            

Guest 2             

Have you previously attended an FCLB Conference? ? Yes No

Registration Status  Voting Delegate Alternate Delegate Other

Friday: "An Ethnic Evening in Old Chicago" - Dinner and door prizes at Maggiano's Little Italy 6:30 p.m.

Will you attend the evening event?*   ? Yes No   Number of Guests @ $50 per person

Thursday: Chicago Tour 9:00 a.m. - 1:00 p.m. - Fee: $35 per person - # attending

Short sleeved Hanes Beefy T-shirts with conference logo - $10 each - advance order only!

#LG       #XL       #XXL

      Registration fee to be paid by * Attendee Other Attendee and Other  

                               Specify if other 

                          Form of Payment* Check Money Order Master Card Visa Cash

   Credit Card Number  (no spaces)

              Expiration Date (mm/yyyy)

        Amount to be paid by attendee

             Amount to be paid by other

Travel Plans

     Arrival Date       Arrival Time

Departure Date Departure Time

 Travel or other information you would like FCLB Staff to know.
 

Special Accommodations 

Are there any special accommodations you need to make your (or your guest's) conference experience more comfortable? (i.e., hearing assistance, accessibility, diet considerations)