NEW JERSEY STATE ASSOCIATION OF CHIEFS OF


THREE DAY PROGRAM—SEE AGENDA FOR TIMES AND LOCATIONS. FRIDAY, SEPTEMBER 21ST—SUNDAY, SEPTEMBER 23RD, 2012 FEE: $600.00


 PLEASE DUPLICATE THIS FORM FOR EACH REGISTRANT.  REGISTRATIONS MUST BE PAID IN ADVANCE BY CHECK OR PURCHASE ORDER.  YOU WILL RECEIVE AN E-MAIL CONFIRMATION WITH HOTEL INFORMATION PRIOR TO THE EVENT.


 CANCELLATIONS MUST BE RECEIVED 14 BUSINESS DAYS PRIOR TO THE COURSE IN ORDER TO BE ISSUED A REFUND.


THE SEMINAR MAY BE CANCELED DUE TO INSUFFICIENT ENROLLMENT.


RETURN THIS FORM TO: NJSACOP


ONE GREENTREE CENTRE, SUITE 201 MARLTON, NJ 08053 FAX #: 856.810.0223


NAME:


TITLE/RANK/POSITION: AGENCY/DEPARTMENT: ADDRESS:


CITY/STATE/ZIP: TELEPHONE: FAX:


E-MAIL ADDRESS: (confirmations will be sent via e-mail)


METHOD OF PAYMENT: CHECK ENCLOSED PURCHASE ORDER CREDIT CARD: ___ VISA ____ MASTERCARD ___ AMEX


CREDIT CARD #: ___________________________________________________________________ EXPIRATION DATE: _______________ BILLING ADDRESS: _________________________________________________________________


______________________________________ SIGNATURE


10


____________________________ DATE


NJSACOP OFFICE USE ONLY DATE RECEIVED _____________


CONFIRMATION FAXED OR E-MAILED ______________ PAYMENT RECEIVED ______________


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