100th Convention UNICO Registration Form

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100th Convention UNICO Registration Form

Presented by

For Online Registration & Payment

Name

Name Nickname

Spouse’s name (if attending)

(If spouse is a member, please complete a separate form) Nickname

Address

City

State

Zip

Cell

Children (if attending)

Yes

How many Children

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Children Name

Children Age

Chapter

District

Office Held

(i.e., National Officer, District Governor, Chapter President, Delegate, Trustee)

Option

Convention Package: $325 per person / $50 for children (12 & under)

Registration Only (For Members not taking the Convention Package)

Friday Night Poolside Cookout (additional $10 fee) Option

Unable to Attend, but would like to Donate

Please disregard this form and click on Donation below.
Donation

Number of Adults

Includes: Registration, Continental Breakfasts, Wednesday Night Icebreaker with Cocktail Hour, Saturday Inaugural Gala with Cocktail Hour

Hidden

X $325 = $

Total

Children

Hidden

X $50 = $

Total

Friday Night Poolside Cookout

Hidden

X $10 = $

Total

Please advise if you have any dietary restrictions or food allergies:

Yes

If yes, please specify

Sub Total

Price: $0.00

Total

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Comments

This field is for validation purposes and should be left unchanged.

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