Ananias Inc. – LA PATHS
Proudly Presents
2nd Annual HIV Client Conference
Friday, June 25, 2010
Please fax completed registration form to 318-227-9991 ASAP
If you have not received confirmation for your registration
within 48 hours please call 318-227-9010
Register Today
1. GENERAL INFORMATION
First Name:_________________________ MI:__________ Last Name:____________________________
Organization:__________________________________________________________________________
Address:______________________________________________________________________________
City:______________________________ State:_______________ Zip Code:_______________________
Date of Birth:_______________ Age __________
Home Phone: ( ) __________________ ______Other Phone: ( ) ________________________
E-mail Address:_________________________________________________________________________
Number of Attendees:______________________
Parent/Guardian Signature if under 18:____________________________________
3. REGISTRATION FEE
Please submit your registration fee with this registration form. Fees are $50 per person. Please make check payable to Ananias Inc. Registration deadline is June 10, 2010.
For questions or additional information, please call (318) 227-9010.
Cancellations and Refunds: Registration fees will be refunded, less a $20.00 administration fee, if cancellation is received in writing no later than June 20, 2009. After that date, registration fees are non-refundable. All refunds will be processed after the conference.
PAYMENT METHOD
Please remit payment of $50.00 by checks or cash in U.S. funds payable to: Ananias Incorporated. There will be a $35.00 fee charged on checks returned by the bank due to insufficient funds.
