Zeta Phi Beta Sorority, Incorporated State of Illinois ____________________________________________________________________________ 2014 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 ____ Life Member (All Categories)
____ Graduate
____ Undergraduate
____ Chapter Basileus
____ Amicae President
____ Amicae
____ Workshop Presenter
____ National, Regional, State Officer/Appointee
____ Financial
____ Unfinancial (Non-Sorority Members)
Financial Status
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. __________________________________________________________________ Special Meal Request:
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Vegetable Plate
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Fruit Plate
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Other ________________________
The registration fee is $15.00 for enveloped postmarked on or before January 20, 2014. DO NOT mail registration forms after January 20, 2014. After January 20th, Sorors and Amicae must register on-site. The on-site registration fee is $25.00 (cash only). Mail the completed form(s) and payment(s) to Zeta Phi Beta Sorority, Incorporated, State of Illinois, c/o 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. (Do not e-mail the registration form to the State Director.) Please make checks and/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: Regional Director, State Director, and as approved by the Illinois State Director.
Registrant’s Signature: ______________________________
Date: ____________________________
PLEASE DO NOT WRITE BELOW THIS LINE.
Date Received __________
Amount __________
Check / MO # __________
Cash
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Exempt
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