NJMCA Pesticide Training Course - Registration Form

(Paper Submission - please send payment and this form by 13 Feb 09)

Name:

__________________________________________________________________

Affiliation:

__________________________________________________________________

Address:

__________________________________________________________________

__________________________________________________________________

Phone #:

(____) ____-_____

Email:

__________________________________________________________________

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

Hilton Casino, Atlantic City :  Tuesday, 10  March 2009 ____ Directions

Crowne Plaza, Monroe Twsh: Tuesday 24 March 2009  

____ Directions

Others attending from your affiliation: (List names and state that registrant is certified 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.