REGISTRATION
FORM
Use
this form to register for the Third Annual Public Lecture
Back From
the War:
A Program for Veterans and the People Who Care for Them
My Contact
Information
Name,
Degree:
Occupation:
Street Address:
City, State,
Zip:
Home Phone:
Work Phone:
Fax:
Email:
Ticket
Price
Tickets:
$15 for lecture ($20 at the door)
Reduced for
Veterans, Active Military & Family Members: $10 for Lecture ($15 door)
Donor Reception:
Additional $100 tax-deductible donation per person
Form of
Payment
I
wish to purchase ___ lecture ticket(s) and ___ ticket(s) to donor reception.
_____ Enclosed
check payable to the NC Psychoanalytic Foundation.
_____ Credit
Card, please check type of card: Visa ___ Mastercard
___
Credit Card
Account Number:
Expiration
Date:
Name (as
it appears on credit card):
Zip Code
(of credit card billing address):
Signature:
Deadline:
To
guarantee space at lecture or reception, registration must be received by February
27.
After deadline,
c
Tickets purchased
in advance will be held at the registration desk.
Please
Mail Form and Check to: