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REGISTRATION FORM 2013 - (ON-LINE - PAYMENT IS REQUIRED BY PAYPAL)
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First Attendee
Yes
No
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REGISTRATION FORM - 4th National Pastoral Care Domestic Violence Leadership Conference Saturday, October 5, 2013 - 8am - 4pm
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Clergy or Leadership Titles Select One
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Name - (Last, First, M.I.)
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Name of your Church
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Address 1 - (Street, Suite/Apt.#)
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Address 2 - (City, State, Zip)
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Cell Phone Number
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E-mail Address
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Executive Assistant Name
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Telephone Number
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Payment Option
PayPal - ALL REGISTRATIONS ON-LINE
Cash/Check or Money Order - MAILED OR ON-SITE ONLY
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Registration Fee
Early Bird Special By June 30, 2013 - $50.00
$55.00
$65.00 At the Door
Donation $_________
No Refunds after August 1, 2013
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Check or Money Order was Mailed:
Option #1
DCA EHS, Inc. P.O. Box 92246, Washington, DC 20090
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