Title: Name of Event :_________________________________________________________________
1 COLORADO FEDERAL FORUM
Name of Event ___________________________________
______________________________
Colorado Federal Forum May 12 2006
Last Day for Registration is May 5 2006.
Cancellations must be submitted in writing to
cj.beasley_at_dfas.mil by May 5th. No refunds will
be made after May 5th no shows will be charged
substitutions welcome.
Attendee Information
Please print or type
For multiple attendees please list names and
information on a separate sheet of paper
Attendee Name __________________________________
_____________________________ Agency Name
__________________________________________________
_______________ Phone ___________________________
___________________________________________
Email Address __________________________________
______________________________ Special
Accommodations Needed (vegetarian diet)
___________________________________
Cost for Hearing Interpreters will be paid for by
their agency
Payment Information
All returned checks will be subject to a 30 fee
Payment by (Circle One) Cash Check
Credit Card Visa or Master
Card Credit Card Number ________________________
____________________________________ Expiration
Date ____________________
Verification Code _____________________ Name as
it Appears on the Card___________________________
_________________________ Cardholders Phone
FAX ____________________________________________
___________ Cardholders Email
__________________________________________________
____________ Credit Card Billing Address Zip
Code ____________________________________________
__ _______________________________________________
_______________________________ Cardholders
Signature _______________________________________
____________________
(This code is the last 3 digits on the back of
the card by the signature)
(Actual POB or address where credit card bill is
sent )
Charge Calculations
Cost per Person
____________________ X Number of
Reservations
____________________ Total Credit Card
Authorized Charge ____________________
Mail or Fax Payment to DFEB Attn CJ
Beasley 6760 E. Irvington Place Denver
CO 80279-8000 FAX 303-676-6666
Phone 303-676-7009 Registrations MUST be
received In the office by May 5 2006
39.00
