DELEGATE * required (Enter NA if not applicable) First Name: * Last Name: * Name for Lanyard: * Position/Title/Rank: *
DELEGATE CONTACT INFORMATION Use different email address if registering more than once, such as, registering family/guests/activities. Email Address* Office Phone: * Cell Phone: *
Will You need Transportation to/from the airport? * Yes No
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AGENCY / ORGANIZATION Agency/Organization Name: * AGENCY ADDRESS Address 1: * Address 2: City: *
IDENTIFYING INFORMATION TCOLE PID #: if applicable to receive credit
NA Session #
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DELEGATE REGISTRATION INFORMATION: JUNE 14-16, 2023
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FAMILY/GUEST/ACTIVITY REGISTRATION: JUNE 14-16, 2023
Delegates may register and pay for additional family/guests or activities separately once the delegate registration is completed. After receiving Confirmation email, reopen the registration page and check the desired family/guests/activities registration.
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If you are paying by checks payable and send to: FBINAA Of Texas c/o Rick Smith Secretary/Treasurer 1919 Highway 35 North, #62 Rockport, TX 78382
Upon receipt of payment, a confirmation email will be sent to the email address provided with a receipt attached. If you have any issues submitting the form, email Rick Smith at ricksmith7000@sbcglobal.net
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