The 14th Annual Professional Training Day Registration
Workshop Selection: Please select one Morning and one Afternoon Workshop
__A1 __A2 __A3 __B1 __B2 __B3
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Name
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Professional License # - must be included with requests for continuing credits
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Address
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Address Line 2
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City/State/Zip
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Email Address for registration confirmation
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Phone
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Name of Agency if coming under agency membership
Please check appropriate amount:
Early Bird Rate: Faxes received/Postmarked by 5 p.m. March 19, 2008.
____ $100.00 - ACONE, Inc. members
____ $140.00 - non-members of ACONE
Regular Rate: Faxes received/Postmarked after March 19, 2008.
____ $115.00 - ACONE, Inc. members
____ $155.00 - non-members of ACONE
Join ACONE now and attend as a member.
____ $50.00 for individual/family membership
____ $100.00 for agency/organization membership
Please consider making a donation to provide for scholarships.
__________ Donation
__________ Total dollars enclosed or to be charged
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MC/Visa/Discover #
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Expiration date
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Three-digit code on back of card
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Name on card
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Signature of cardholder
Mail payment to: ACONE, Inc., 45 Lyman Street, #2, Westborough, MA 01581.
Registrations charged on MasterCard, Visa or Discover may be faxed to us at 508.366.6813
