Registration

Please fill in the information below to secure your seat for the event. A confirmation email will be sent to you immediately confirming your registration. Due to the overwhelming popularity of this event and the limited seating, there will be NO REFUNDS once a confirmation of purchase is sent by the NW CT Chamber of Commerce to the registrant.

Attendee Information

* Indicates required fields

First Name:

Last Name:

Title:

Company:

Work Address:

City:

State:

Zip:

Work Phone:

* ( Format: (555) 555-5555 )

Home Address:

City:

State:

Zip:

Home Phone:

( Format: (555) 555-5555 )

Email:

How did you hear about the WOW Forum?

Seminar Information

I will attend the full seminar. (~~$125~~) (Only $99 if ordered by August 15, 2009)

Morning:

Afternoon:

Scholarship Program - New This Year!!

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)

My company has received a sponsor code.

Sponsor Code:

I will be paying by check.

Your seat will be reserved upon receipt of payment. Checks must be recieved by the NW CT Chamber of Commerce within five (5) business days from the day of registration. If payment is not recieved, registration will be cancelled. A confirmation of payment will be sent via email when check is received and processed.

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 :