Online Conference Registration

Online Registration Form

Title *

Full Name *

Member #

Member Type *

Agency

Title

Mailing Address

Address Line 2

City *

State *

Postal / Zip Code *

Cell Phone *

E-mail *

Spouse / Guest Name

Emergency Contact Name (Full Name) *

Emergency Contact Number *

Training Certificate

I will require a training certificate for my employer. I will NOT require a training certificate for my employer.

DIETARY MEAL REQUIREMENT (If yes, please check one)
VEGAN VEGETARIAN

Members must be financial to register at the member rate.
Senior members must be 60 years of age to qualify for the senior rate.
Individuals registering as Spouse/Guest must be registered with a fully registered attendee

ON-LINE REGISTRATION WILL BE ASSESSED A 4% PROCESSING FEE

* Marked are Required Field.

If you have any questions or require assistance for a disability, please contact: NABCJ, NC Central University, P.O. Box 20011-C, Durham, NC 27707, telephone :( 919) 683-1801; Fax: (919) 683-1903, or call us toll free at, (866) U4NABCJ (866) 846-2225