Zeta Phi Beta Sorority, Incorporated State of Illinois ____________________________________________________________________________ Illinois State Leadership Academy – Registration Form Winter Workshops Series for Sorors and Amicae Please type or print legibly.
Last Name
_______________________________
First Name _______________________________
Mailing Address __________________________________________________________________________ Telephone Number ____________________________
E-Mail Address ____________________________
Chapter’s Name
____________________________
Chapter Location __________________________
College/University ____________________________
College/University Location __________________
Registration Status ____ Undergraduate
Financial Status
____ Graduate (Advisor)
____ Graduate (Guest / Presenter)
____ Chapter Basileus
____ Amicae President
____ Amicae
____ Financial
____ Unfinancial
In the case of an emergency, please contact: Name _______________________________________
Telephone Number _________________________
Additional Information: I have a disability and may require accommodations to fully participate in the workshops. Please described the accommodations needed. __________________________________________________________________ ________________________________________________________________________________________ The registration fee is $10.00 for enveloped postmarked on or before January 27, 2013. (preferred method + entry in raffle for incentive gift) DO NOT mail registration forms after January 27, 2013. After January 24th, Sorors must register on-site. The on-site registration fee is $15.00 (cash only; no meal preference; no gift; and no raffle entry). Mail the completed form(s) and payment(s) to Zeta Phi Beta Sorority, Incorporated, State of Illinois, c/o Soror Tina Davis, Illinois State Tamias-Grammateus, P.O. Box 439392, Chicago, IL 60634-9392 Mail a copy of the registration form to Soror Connie V. Pugh, P. O. Box 87324, Chicago, IL 60680. Please make checks or money orders payable to Zeta Phi Beta Sorority, Incorporated, State of Illinois. A fee will be assessed on NSF checks. Total Enclosed: $________
Exempt ________
List Exempt Reason: ___________________________
Exempt List: Regional Director, State Director, and Workshop Presenters (approved by the State Director).
Please select your sandwich choice and bread type from the list below. Circle R for regular white bread and W for wheat bread. All lunch orders include a sandwich, chips, cookie, and canned soda or bottled water. Please make only one sandwich selection. _____ _____ _____ _____
Turkey Breast with Swiss Cheese Smoked Ham with Swiss Cheese Tuna Salad with Swiss Cheese Roast Beef with Provolone Cheese
R R R R
W W W W
_____ _____ _____ _____
Registrant’s Signature: ____________________________
Cold cut combo Subway Club Vegetarian Sandwich BLT Sandwich
R R R R
W W W W
Date: __________________________________
PLEASE DO NOT WRITE BELOW THIS LINE.
Date Received __________
Amount __________
Check / MO # __________
Cash
□
Exempt
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