Please fill in the following information:

First Name
Last Name
Preferred Name
Title
County
Mailing Address
City/State/Zip	,
E-Mail Address
Program Area
Phone (day)	(include area code)
Fax	(include area code)

Method of Payment	Personal Check	#
	County Check	#

	Cost	Quantity
Full Member Registration Received before July 11, 2011	$85
Full Non-Member Registration Received before July 11, 2011	$100
One Day Member Registration	$55
One Day Non-Member Registration	$60
One Day Registration for: Thurs. Fri.
Full registration includes Sept. 20 Lunch & Dinner & Sept. 21 Breakfast
Additional Guest Meal Per Person or Meal
Thursday Lunch	$23
Awards Banquet	$30
Closing Breakfast	$15
Guest Name
	Total	$
Please list any dietary restrictions below (e.g. allergies or vegitarian)

Registrations received after July 11, 2012 will have a late fee of $10 for members and $20 for non-members.
Registrations received after August 1, 2012 will have a late fee of $40 applied.

When you have completed this form and everything is correct, click on the "Register" button below.
Mail a hard copy of the following page, along with your check made payable to NCAEPAAT, to:

Malinda Davis 304 S. Morgan St Room 123 Roxboro, NC 27573