FAASA '23 Registration Form

2023 NATIONAL BLACK STUDENT LEADERSHIP INSTITUTE

“FAASA: Building Tomorrow's Leaders Today”

November 9th-12th, 2023

Melbourne, Florida
Campus:
Name of Institution:*
Name of Chapter:*
Advisor's Information
Name of Advisor*

First NameLast Name
Address for Advisor*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Advisor's Phone Number*

Area CodePhone Number
Advisor's E-mail*
Chapter President's Information
Chapter President's Name

First NameLast Name
President's Phone Number

Area CodePhone Number
President's E-mail
Payment Information
Number of Student Delegate(s) $150.00 per Student
Number of Advisors Delegate(s) $150.00 per Advisor
Number of Banquet Tickets $75.00 per person
Number of Luncheon Tickets $50.00 per person
Annual Chapter Membership Dues $150.00
Total
Please List The Names Of All Delegates Attending Conference
(Do Not Include the Above Listed Advisor and President)

"If your school has more than 15 delegates,please complete a second form without the payment information."
Delegate1

First NameLast Name
Office1
Delegate2

First NameLast Name
Office2
Delegate3

First NameLast Name
Office3
Delegate4

First NameLast Name
Office4
Delegate5

First NameLast Name
Office5
Delegate6

First NameLast Name
Office6
Delegate7

First NameLast Name
Office7
Delegate8

First NameLast Name
Office8
Delegate9

First NameLast Name
Office9
Delegate10

First NameLast Name
Office10
Delegate11

First NameLast Name
Office11
Delegate12

First NameLast Name
Office12
Delegate13

First NameLast Name
Office13
Delegate14

First NameLast Name
Office14
Delegate15

First NameLast Name
Office15
Should be Empty:

Payment Information