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Virginia Department of Aviation
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Note: online registration may not work with certain government cards. If you have problems either fax or mail your registration or call Erika LaLuzerne at 414.466.6060 ext. 329. OR:
OR:
-------------------------------------------------------------------------------------- 1) Contact Information: (please print) Name: ____________________________ Title: ____________________________________ Preferred Name/Title on Badge: ___________________________________________________ Organization:__________________________________________________________________ Address (Street, City, State, Zip): __________________________________________________ Phone: (Office) ____________________________ (Cell) ______________________________ Email: _______________________________________________________________________ 2) Registration Fee: $150.00 After September 1, 2005, Registration will be $180.00. 3) Send Registration To:
Mail to: NCAE,
c/o Ken Cook Co. Attn: 2005 LCASE Conference coordinator Phone: 414.847.1200 - Ken Cook Or Fax to: 414.466.0840, Attn: 2005 LCASE Conference coordinator Website: www.lcase.info 4) Payment Information: Checks: Make checks payable to: NCAE Credit Card: Charge My Credit Card - Name on Card: _________________________________________________________ Circle: Visa / MasterCard Card Number:___________________________________ Expiration Date: __________________ Card Holder’s Signature: ___________________________________________________________ Card Holder’s Phone (Daytime): _____________________________________________________
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LCASE 2007 Contact: mail@lcase.info Website Contact: webmaster@lcase.info
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