Personal Information

Full Name:

Address:

City:		State:	Zip:
Phone:		Fax:	Email:

Method of Payment - Pre-payment required for non GMA SHRM members. Total to be charged: _________ Mastercard       Visa       Credit Card Number:     Exp. Date: Three digit verification number (on back of credit card): Name as it appears on card: Billing Address for Credit Card:

Please contact the Rotary District 6250 office if special assistance is needed.
No refund will be given for cancellations after noon on Wednesday before the event.