West Virginia Civic Life Institute
Registration
June 21-22, 2004 - University of Charleston - Charleston, WV
Please complete and return this application form along with your registration fees by June 15, 2004.Space is limited, so early registration is advised. Registrants will be mailed an information packet.
__________________________________________________________________________
Name Designate preference for name tag
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Mailing address you prefer
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City State ZIP code
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County Email address
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Work phone Home phone Fax
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Profession or organization
Check those that apply:
_______ $95 for registration, materials, meals
_______ $30 for campus lodging Sunday, June 20
_______ $30 for campus lodging, Monday, June 21
______________________ Total due
_________ Enclosed ______ Bill my organization
Name and address of organization _______________________________________________
_________________________________________________________________________
If you require special services, please call ahead to let us know.
Checks should be made payable to the West Virginia Center for Civic Life.
Please mail registration and fees to the West Virginia Center for Civic Life,
2300 MacCorkle Avenue, SE, Charleston, WV 25304.
For more information: Betty Knighton at 304-344-3430 or KnightonB@aol.com