Registration Form
________ Please sign me up for "Breaking the Boundaries"
Company Name: ________________________________________________________________________
____________ People Attending at
_______ $10 per person (no table) Check #: __________
_______ $60-Full Table (includes one admission)
________$30- Half Table (includes one admission)
Pay by Credit Card
Type of Card: Visa __________ Master Card __________
Name of Card Holder: ____________________________________________________________________
Account Number _______________________________ Expiration Date: _______________
Address of Cardholder: ___________________________________________________________________
V-Code Number: (3-4 digit number on back of card) _____________ Zip Code: ______________
Signature: _____________________________________________________________________________
Phone #: _______________________________ Amount Charged: ___________________ |
Participating Chambers: Allen Park, Belleville, Canton, Dearborn, Dearborn Heights, Farmington/Farmington Hills, Garden City, Lakes Area, Livonia, Novi, Plymouth, Redford Township, Southern Wayne County, Wayne,
& Westland |