REGISTRATION FORM 2014 Virginia/West Virginia State Conference Friday October 3, 4p-9p & Saturday, October 4, 7:30a-5:30p A Centennial Year Experience: Momentum Into the Next Century Holiday Inn 2000 Staples Mill Road Richmond, Virginia 23230 (Please write legibly) Full Name: ____________________________Membership #_______ DSC/Life Member________ Current Chapter: _________________________________________________________________________________________ Preferred Mailing Address:__________________________________________________________________________________ City: ________________________________ State/Province: ______________________ Zip/Postal Code: _________________ Country: _____________________________ Telephone: (______)__________________ Fax: (______)____________________ Email: __________________________________________________________________________________________________ 1. Registration Fees (Includes lunch, breaks, souvenir journal, and workshops) POSTMARKED & PAID PLEASE CHECK APPROPRIATE REGISTRATION FEE:  $35 (Alumni Check or Money Order ONLY)  $25 (Students Check or Money Order ONLY)  On-Site Registration $35 (Cash or Money Order) Total for Registration Fee $ ______________ Total for Ad(s) Fee $ ____________ Phi Beta Sigma Virginia State License Plate Fee:  Yes, $10 (PLEASE complete the included VSA10 Form)  I have already paid for the VA License Plate  No, I’m not interested. Reason_____________________________________________________________ _____________________________________________________________ 2. Total for VA License Plate Fee $ ___________ Lunch (See Attached Menu): Deli Sandwich Buffet Turkey, Ham, Roast Beef, Chips and Drinks $ _INCLUDED__ TOTAL ENCLOSED: $ ___________ Cancellations/Changes and Refunds: Fees are non-refundable. PAYMENT METHOD: Check or Money Order must be made payable to: Phi Beta Sigma Fraternity, Inc./Iota Sigma. There will be a $25.00 fee charged on checks returned by the bank due to insufficient funds. Registration confirmation/receipt and further information will be mailed. Pay via paypal on the Iota Sigma website at www.richmondsigmas.org Mail completed registration form with payment to: Email: [email protected] Website: www.richmondsigmas.org Phi Beta Sigma Fraternity, Inc./Iota Sigma Chapter 2014 VA/WVA State Conference P. O. Box 25966 Richmond, VA 23260 The 2014 Virginia State Conference is graciously hosted by the Iota Sigma and Zeta Eta (UVA) Chapters