Print & complete this form and mail it with your payment to NYAPSA (see address below). Fill out one form per conference registrant please. Print or type your name, title, and organization exactly as you would like it to appear on your conference name tag. A conference “Attendee List” will be arranged in alphabetical order based on the last name of each registrant.
[REMINDER: Hotel reservations must be made directly with the Hilton Garden Inn.]

Name ______________________________________________
Title _______________________________________________
Agency _____________________________________________
Address ____________________________________________
Phone ____________________    FAX ___________________
E-mail ______________________________________________

REGISTRATION FEES:

Postmarked by April 2, 2010:                    Postmarked after April 2:
Member:              __ $85.00                         Member:              __ $100.00
Non-Member*:    __ $105.00                       Non-Member*:    __ $120.00
(* fee includes $20.00 membership!)


ONE-DAY REGISTRATION FEES:

Postmarked by April 2, 2010:                    Postmarked after April 2:
Member:              __ $60.00                         Member:              __ $80.00
Non-Member*:    __ $80.00                         Non-Member*:    __ $100.00
(* fee includes $20.00 membership!)

Total amount enclosed:    $_______

Mail this form with your check or voucher (payable to NYAPSA) to:
NYAPSA Conference
PO Box 5153
Poughkeepsie, New York 12602

Please indicate the meal functions you will be attending:
___    Lunch, Sunday April 25 (12:00 - 1:30 PM)
___    Lunch, Monday April 26 ( 1:00 - 2:30 PM)

If you require a vegetarian meal, check here:   ___