NCRMA

RLPA Registration Form

May 16 Meeting

General Information:

You may register up to 6 on this form.
To receive early-bird registration discount, email the completed form by August 21.
*Confirmations will be sent via email upon receipt of registration form.
Badges and all other meeting materials will be distributed at the registration desk.

August 22 Registration Fees


REGISTRATION FEES
RLPA Member(s)	# Attending	@ $	= $
Total Payment To Charge:			= $

PAYMENT INFORMATION
Credit Card Type
Credit Card Number
Name on Credit Card
Exp. Date SEC

REGISTRANTS
Company Name
First and Last Name
#1 Member Name
#2 Member Name
#3 Member Name
#4 Member Name
#5 Member Name
Address
City, State Zip
Phone
Fax
*Email
WAIVER OF LIABILITY
The undersigned, in consideration of his/her registration at the 2008 Retail Loss Prevention Association of the Carolinas, releases, holds harmless and discharges the association, from any and all actions, claims and demands which may arise out of an accident, casualty or occurrence during said meeting. Your signature below acknowledges acceptance of these provisions of registration for all those listed on this form.
Please type name in lieu of your signature:

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