Conference Attendee - Registration Form

Conference Attendee - Registration Form
Attendee Details:
Full Name*

First NameLast Name
Agency
Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Attendee E-mail
example@example.com
Billing Contact: Name & Email

Add additional Attendees

	Full Name	Email Address	Contact Number
1
2
3

Cost per person: Members $100.00 per person

Non-members $150.00 per person

You will be invoiced. For information, please contact:

Juliette M. Parker

CONNPAC Treasurer

City of Groton Police Department

295 Meridian Street

Groton, CT 06340

(860) 446-4154
Should be Empty: