DOWNLOAD AS A PDF 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 Email CellChildren (if attending) Yes No How many Children12345Children 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 AdultsIncludes: Registration, Continental Breakfasts, Wednesday Night Icebreaker with Cocktail Hour, Saturday Inaugural Gala with Cocktail HourHiddenX $325 = $TotalChildrenHiddenX $50 = $TotalFriday Night Poolside CookoutHiddenX $10 = $TotalPlease advise if you have any dietary restrictions or food allergies: Yes No If yes, please specify Sub Total Price: $0.00 Total Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.