CSA Member Dinner Meeting

Member Dinner and Networking Meeting Registration Form

June 4, 2019

Casa Mia at the Hawthorne, Berlin, CT
5:00 pm - 7:30 pm
(Registration starts at 4:30 pm)

Company

Address

City* State* Zip Code*

Phone

Name # 1

Email # 1*

Name # 2

Email # 2

Name # 3

Email # 3

Name # 4

Email # 4

Dinner Fees = $75.00 for the first person; $65 for each additional attendee

Sponsor Fees = $100.00

First Attendee

Fee = $75

# Additional Attendees

Fee = $65 per person

Sponsor

Fee = $100

Total Payment

Payment Type

Master Card VISA American Express

First Name

Last Name* Email*

Account #

Security #*

Exp. Month

Exp. Year* Billing Zip Code