2011 PSRC Conference in the Capital

Please complete this form to enter your registration information for the above event. Use this form only if paying by credit card. NOTE: Do not enter punctuation in your responses or they will be rejected. "/" or "-" marks are acceptable.

1. First Name
2. Last Name
3. Credentials (separate with a "/" mark if more than one).
4. AARC Membership Number (if you are not a member, enter NONE)
5. Mailing Address - Street
6. Mailing Address - City
7. Mailing Address - State
8. Mailing Address - Zip Code
9. Email Address (if you don't use email, enter NONE)
10. Phone Number (home or cell)
11. Name of Workplace (or School)
12. How Did You Hear About This Event?

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