NJMCA Pesticide Training Course - Registration Form

(Paper Submission - please send payment and this form by 12 Feb 08)

Name:

__________________________________________________________________

Affiliation:

__________________________________________________________________

Address:

__________________________________________________________________

__________________________________________________________________

Phone #:

(____) ____-_____

Email:

__________________________________________________________________

Course location and date you will attend:  (check one)

Resorts Casino, Atlantic City :  Tuesday, 11  March 2008 ____ Directions

Crowne Plaza, Monroe Twsh: Tuesday 25 March 2008  

____ Directions

Others attending from your affiliation: (List names and state only)

                List Name                                                                      State
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

 

 Please make checks payable to: NJMCA
This form should be printed out and mailed to:
Cumberland County Mosquito Control Division
800 E. Commerce St.
Bridgeton, NJ 08302
Attn: Heather Lomberk, phone 856-453-2170
Fax: 856-459-9692
 Payment Amount Due ($70.00 per person): $________
 Thank you for your submission.   Cancellations and switching attendance locations must be received no later than 48 hours prior to the meeting date. Smoking will not be allowed in meeting rooms.