Please highlight and print out the text of this form. Mail the completed form to the address at the bottom of this page.

AMTA – Delaware Chapter

Class Registration Form

Class Name:  ______________________________    Class Date: ___________________

Class Location:  ____________________________    Class Fee:  ___________________

Registrant’s Name: _______________________________________________________

Are you an AMTA Member?     Yes     No                         If yes, Member ID: _____________

Address:  ______________________________________________________________

City/Town: _____________________     State: _____   ZIP Code: ___________________

Phone Numbers where you may be contacted: 

Phone Number 1:_________________  Please indicate:   Home   Work   Cell   Other: _____

Phone Number 2: ________________   Please indicate:   Home   Work   Cell   Other: _____

Email Address:  __________________________________________________________

Signature: _____________________________________   Date: ____________________

 Please remit payment by check or money order (payable to the AMTA – DE) to hold your registration.

                                Please send registration form with payment to: