A downloadable registration form is available here.
__Visionary - $15,000 __Leader - $10,000 __Gold Sponsor - $5,000 __Sponsor - $2,000
__Seat(s) at $125 each ($150 at door)
Attendee(s): ______________________________________________________________________
Affiliation:_________________________________________________________________________
Address:__________________________________________________________________________
Town, State, Zip: __________________________________________________________________
Phone: __________________________________ Fax: ___________________________________
Email: ___________________________________________________________________________
__ Check enclosed __Check sent (Faxes only) __Credit Card __Pay at the Door
__ Visa __Mastercard __American Express --- Card Number: ______________________________
Name (as it appears on card): ______________________________Expiration Date: _____________
Registration forms may be mailed to our office at 24 Woodbine Ave., Suite One, Northport, NY 11768 or faxed to 631-754-4452.
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