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GCPA Event Registration Form

Georgia Count on Concrete Legislative Day

Wednesday, March 14, 2012
 Sloppy Floyd Building - Empire Room
 Two Martin Luther King Jr. Drive - Atlanta, GA

Sponsorship Commitment Form
Please register one person at a time
Select Event:

   Georgia Count on Concrete Legislative Day
Attendee Information:
PLEASE provide your HOME address in Georgia with your
9-digit zip code so we can identify your Georgia Senate and House
Representatives to organize legislative visits
Name:
Title:
Agency/Firm:
** Home Address:
Address 2:
City and State:    
  Find Your Zip Code:
Zip+4
Phone:
Fax:
Email:
Occupation:
 
 Fees:
 
List Your District # and Representatives below
  Find Your Georgia Legislators:  
House Rep: Dist. #:
   
Senator Dist. #:
   
Please select events you will attend
 
   
Select your Payment Method
Type Payment:
Check

Please make check payable to:

ACPA-SE Chapter
2180 Satellite Boulevard, Suite 300
Duluth, GA 30097
 
Credit Card  (VISA or MASTERCARD)
 
For the safety and security of your credit card information,
our policy is to accept credit card information by fax or phone only.
Please call 770-497-0111 to pay by credit card.

Thank you.
Invoice/Purchase Order

PO Number:
Comments/Questions:
 


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