Method of Payment

___ Money Order ___Check ___Pay Pal

(U.S. funds only payable to AMTA DE Chapter)

Conference Fee $__________

Amount Paid $__________

Balance Due $__________

If paying via Pay Pal please also fill out and send this form by mail

Mail this form with payment to:

AMTA Delaware Chapter

Attn: Theresa Porta

24 Whitaker Avenue

Northeast, MD 21901

Cancellation Policy

All cancellation requests must be made in writing.

The fee paid will be refunded less $50.00 if the cancellation notice is received within 15 days of the start of the class.

No refunds will be issued 15 days from the start of the class.

Name ___________________________________________________________________

Address ___________________________________________________________________

___________________________________________________________________

Telephone # for questions_____________________________________________________

E-Mail address ___________________________________________

May we confirm your registration via this e-mail address? _________

AMTA Member Number and State______________________________________________