Fall Conference 2011

 CLICK HERE FOR APPLICATION FORM IN WORD

Limited Seating – Pre registration required – No walk-ins

18 hours of In-Service Credit

New York State Training ID #  NY________________ (Do not use Social Security Number)

FDID Number  __ __ __ __ __   Architect/PE  ID________  (AIA/PE credits NOT available)

Student Name: Last ______________________________ First ___________________________ MI____

Mailing Address: ____________________________City ___________________State _____Zip_______

Phone Number (____)__________   Cell Number (____)__________   Fax Number (____)____________

Title: __________________________Municipality(s)/Firm: ____________________________________

E-mail__________________________________________ (indicate accurately, i.e. upper/lower case, all dots, etc)

Student Signature________________________________  Date _________________

REGISTRATION FEE:      Circle One:    3 Day - $250.00  member   $300.00 non – member

Per Day $100.00 member    $125.00 non member.  Indicate days_______________________

All vouchers and purchase orders are required net 30 days. Registrant is responsible for payment.

Deadline for registration is August 26, 2011.  Payment is required with registration.

Program Schedule Subject to Change Without Notice

AMOUNT ENCLOSED: $________________Check # ___________Voucher # __________ PO#______________

Make Checks Payable to:  WSTBOA EDUCATIONAL CONFERENCE

Return upper portion with payment to:

Allan Zurawski, Treasurer                  Fax 716-363-0058                                         

WSTBOA Conference                          Phone 716-366-9858 days                             

342 Central Ave                                  Phone 716-366-8376 evenings                                   

Dunkirk, NY 14048                             e-mail:  bills2222@msn.com