REGISTRATION FORM Cooperative Initiatives’ 2010 Chapter Leaders’ Retreat
ATTENDEE NAME: CHAPTER: CHAPTER POSTION: CREDIT UNION POSTION: CREDIT UNION: CREDIT UNION ADDRESS: CITY:
STATE:
Zip:
E-MAIL ADDRESS: TELEPHONE NUMBER: CELL PHONE NUMBER: FAX NUMBER: HOTEL INFORMATION: ARRIVAL DATE:
DEPARTURE DATE:
EMERGENCY CONTACT INFORMATION NAME: TELEPHONE NUMBER: CHAPTER HISTORY INFORMATION HOW MANY YEARS HAVE YOU SERVED ON THE CHAPTER BOARD? HOW MANY POSITIONS HAVE YOU HELD ON THE CHAPTER BOARD? (please list any below)
Please fax to: Jeanie Henson, LSCU Member Relations Specialist, 850.558.1039