Registration

Attendee Information

* Indicates required fields

First Name:

Last Name:

Title:

Company:

Address:

City:

State:

Zip:

Phone:

* ( Format: 555-555-5555 )

Billing Address:

City:

State:

Zip:

Email:

Seminar Information

Registration Fee. ($125)

Morning Seminar Choices (choose one):

Afternoon Seminar Choices (choose one):

Scholarship Program

Yes, I would like to contribute to the WOW! Forum Scholarship Program. Four scholarships will be awarded; two to adult women for career advancement and two to adult women to attend the forum.

$1 $5 $10 or other amount $

Payment Information (via secure connection)
Payments are non-refundable.

My company has received a sponsor code.

Sponsor Code:

I will be paying by check.

Checks must be received by the NW CT Chamber of Commerce within five (5) business days from the day of registration to avoid cancellation.

Make Checks Payable To:
     Northwest Connecticut's Chamber
     333 Kennedy Drive, Suite R101
     P.O. Box 59
     Torrington, CT 06790

I will be paying by credit card.

A $4.00 service fee will be added to all credit card orders.

	*
Card Type	*
Card Number	* (no spaces)
Exp Date	* (MM/YY)
CVC Code	(3 digit code found on back of card)

Please enter the numbers/letters in the picture to the left in the box below.

Validation :