Florida Womens Political Network

Board of Directors Meeting &Tallahassee Days 2012

Registration Form

Please Print

Name_______________________________________________________________________________

(AS YOU WISH IT TO APPEAR ON YOUR NAME TAG)

Club ________________________________________________________________District #:_______

Address_____________________________________________________________________________

City_________________________________________State______________Zip Code_____________

Home Phone _____________________________Work Phone ____________________________

E-mail_________________________________________ Cell Phone _______________________

Employer: __________________________________________________________________________

(This information is needed for our reporting to the IRS.)

Occupation: ________________________________________________________________________

Registration fee $85.00 before February 6^th ___________________

Registration fee after February 6^th $100.00 ___________________

*Guest for dinner $40.00 ________________________________

Guest Name/s: __________________________________________________________

If guest will be accompanying us to the Capitol on Monday there will be a $3.00

Transportation charge. # _________ people at $3.00 __________________

*Guest are not permitted in meeting/s only those functions that they have paid for, per FWPN Standing Rules.

Total enclosed $ ____________________________

Mail this completed Registration Form and your check payable to FWPN to:

Pat Cogswell, FWPN Treasurer Hotel reservations

5902 Golden Road Quality Inn & Suite

Sebring, FL 33875-6099 2020 Apalachee Parkway

Email: patscogswell@gmail.com Tallahassee, FL

Phone: 863-471-2735 850-877-4437
Rooms $89.99/single or double

Mention FWPN to receive this special rate by January 12th, 2012.

You can charge your registration; we accept Master Card and Visa ONLY. No Debit Cards.

Acct. # ____________________________________________Visa___ or Master Card____

Expiration Date: _____________________

Name as it appears on the card:_________________________________________________

REFUND POLICY: FWPN cannot refund registration fees after February 6th, 2012.

Please note that once meal functions are confirmed, the FWPN is responsible for the payment