Arizona Council of the Blind

2010 Annual Membership Convention

Registration Form

Please complete one form per person. Do not include multiple registrants on the same form.

TODAY'S DATE (MM/DD/YYYY):

First Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State/Province:
ZIP Code/Postal Code:
Telephone:
Phone AREA CODE:
Phone NUMBER:

Email Address:

Exhibitor Company Name if registration is for exhibitor:

H2>Program Format Choice
Program Form in Large Print Program in electronic Form Program Form in Braille

Are you a member of the Arizona Council of the Blind?
Yes I am a Member of Arizona Council No I am not a Member of the Arizona Council I do not know if I am a member of the Arizona Council

Banquet Preference - Choose one.
Banquet Meal Beef> Banquet Meal Chicken> Banquet Meal Vegetarian> I’m not attending the banquet >

REGISTRATION FEE
Registration after March 31:
Member Registering after March 31 $20.00 None Member registering after March 31 $40.00

2010 AzCB Scholarships and Awards Scholarship Luncheon $20.00

2010 AzCB Banquet $35 for all >Banquet $35.00

Total all the boxes checked add registration amount and enter amount here

Friday & Saturday Continental Breakfast Free for all attendees

Method of payment (i.e. PayPal or Print and Mail) Using PayPal on next screen
Mailing Fee

Make check payable to the Arizona Council of the Blind or AZCB. You may pay for multiple registrants with one check or money order, but there needs to be an application for each person attending.

Instructions For Mailing Registration Forms and Payments

Send your completed Registration Form and payment to the following address.
Sharon Carpenter, Secretary
3124 E. Roosevelt St. Suite. 4
Phoenix, AZ 85008-5088

Hotel Information

The Convention will take place at the
Crowne Plaza Phoenix Airport
4300 EAST WASHINGTON
PHOENIX, AZ 85034 UNITED STATES
Hotel Front Desk: 1-602-273-7778
Hotel Fax: 1-602-275-5616

http://www.cpphoenixaz.com/light_rail/index.cfm

For More Information

For more information about the 2010 AzCB Convention, contact Ron Brooks at ronlbrooks@msn.com or by phone at (480) 221-4387.

Comments"

Submit will send an E-mail of this form to the AZCB.