(PLEASE PRINT ONE NAME PER FORM)

(PLEASE PRINT ONE NAME PER FORM)

Name_______________________________________ __/____/____ LAST

FIRST

Date

Name__________________________________________ __/____/__ FIRST

LAST

Date

Address __________________________________________________ City _______________________State _______________Zip________ Phone _______________________Email _______________________

Address __________________________________________________ City _______________________State _______________Zip________ Phone _______________________Email _______________________

I will attend the 2012 convention as: ___ a delegate for group # _______ ___ an FA member from group #________ ___ a World Service Board member from group # ________ ___ a friend (or guest) of an FA member of group # ________ ___ other (please specify)_____________________________________

I will attend the 2012 convention as: ___ a delegate for group # _______ ___ an FA member from group #________ ___ a World Service Board member from group # ________ ___ a friend (or guest) of an FA member of group # ________ ___ other (please specify)_____________________________________

Name to appear on badge _________________________________ Full registration: Amount (all workshops, speakers meals and snacks) $130 $ ______ Saturday and Sunday only: (all workshops, speakers, Saturday meals and snacks) $110 $______ Saturday dinner preference (indicate choice) ____ Filet of halibut ____ Poulet Diana (chicken and shrimp) ____ 9 oz. top sirloin steak ____ vegetarian ____T shirts: (adult sizes only)circle M L XL XXL $15 $______ TOTAL AMOUNT DUE: $ ______

Name to appear on badge _________________________________ Full registration: Amount (all workshops, speakers meals and snacks) $130 $______ Saturday and Sunday only: (all workshops, speakers, Saturday meals and snacks) $110 $______ Saturday dinner preference (indicate choice) ____Filet of halibut ____ Poulet Diana (chicken and shrimp) ____ 9 oz. top sirloin steak ____ vegetarian ____T shirts: (adult sizes only) circle M L XL XXL $15 $______ TOTAL AMOUNT DUE: $______

REGISTRATION CLOSES MAY 14 Note: Rooms are not included in this form. See the flyer for room reservations. Make one check for all your applicants payable to: FA Convention 2012 Mail check and form(s) to: FA Convention 2012 ℅ Randy B. 6920 Country Oaks Dr. Highland, CA 92346

REGISTRATION CLOSES MAY 14 Note: Rooms are not included in this form. See the flyer for room reservations. Make one check for all your applicants payable to: FA Convention 2012 Mail check and form(s) to: FA Convention 2012 ℅ Randy B. 6920 Country Oaks Dr. Highland, CA 92346