Registration Form - August 7 & 8, 2009

 
 Name________________________________________________________________

 Address______________________________________________________________

 City/State/Zip________________________________________________________

 Telephone Number_______________ E-Mail Address_____________________

Amount enclosed________________  Date________________________________

 

  PLEASE CHECK THE DATE(S) YOU WOULD LIKE TO ATTEND

**  If postmarked by July 10, 2009
       
       Friday, August 7 only  ($20)  _______

      Saturday, August 8 only   ($50)   _______

      Friday, August 7 and  Saturday, August 8  ($60)   _______

      A Polish-American buffet luncheon is included in the price of
      Saturday's registration fee.

               *****************************************************

**   If postmarked after July 10, 2009
                            
        Friday, August 7 only  ($25)   __________

       Saturday, August 8 only   ($55)  __________
                            
       Friday, August 7 and Saturday, August 8   ($70)___________

 

 

  *   Please circle the lectures you would like to attend on the
      Lecture Selection Form.

  ** If you would like a Consultation Appointment with one of our experts, please
       fill out the Consulation Appointment Form.

         PLEASE RETURN THE FORMS ALONG WITH YOUR
                              REGISTRATION FORM.

 

  Please make checks payable to PGSCTNE and mail this form with your
  payment to: Diane Szepanski, Treasurer, 138 Fern Drive, Plantsville, CT 
  06479

   Please check here ________ if you would like confirmation.  Please enclose
  a self-addressed stamped envelope or provide your E-mail address above so
  we can send you the confirmation electronically

  For further information, please call Diane Szepanski, 860-919-6333 and
  leave your name, telephone number, and postal or e-mail address or
  e-mail us at Szepanski@ccsu.edu.