2013 NC Black Summit Conference Registration
Thank you for your interest in attending the NC Black Summit. To reserve your seat, please fill out the information below.
First Name
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Last Name
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Organization
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Address 1
Address 2
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City
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State
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Postal Code
Business Phone
Fax
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Email Address
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REGISTRATION FEES
(Registration includes: Meal Functions, Work Sessions, Conference Tote, Program Booklet and Proceedings, and Social Events)
Early Bird - $149 (January 21—March 25)
Regular - $175 (March 26 - April 24)
Onsite - $199 (April 25)
Student/Spouse $99 *(Covers meal and workshop functions only-no promotional gift)
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METHOD OF PAYMENT
Check
Money Order
Credit Card
Name on Card
Credit Card Type
Visa
MasterCard
Credit Card Number
Expiration Date (mm/yy)
CVC: (on back of card)
Do you belong to a member organization? (Please check all that apply)
The NC Black Legislative Caucus
The NC Association of Black County Officials
The NC Conference of Black Mayors
The NC Conference of Black Municipal Officials
The NC Association of Black School Board Members
Are you a member of a support organization? (Please check all that apply)
Old North State Medical
NAACP
Fraternal Organization
Black Lawyers
The NC CDC Initiative
The NC Black Leadership Caucus
Faith Based Organization
Other
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Did you attend last years conference?
Yes
No
Make Checks payable to:
The NC Alliance of Black Elected Officials
P.O. Box 26615
Raleigh, NC 27611
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