North Carolina Desert Conference

June 10-13, 2010

Registration Form

Advance Registration: $90 On-Site Registration: $100

Today’s Date_____________________ Advance Registration Deadline: May 31, 2010

Title:_____________________________ (Ill.Potentate, Ill.Commandress, PP ,PC, Dt., Noble, Imp. Officer Title)

Office Use Only

Registration Number

Confirmation Number

________________________________________________________________________

(First Name) (Last Name)

________________________________________________________________________

(Address) (City, State, Zip)

_________________________________ ___________________________________

(Temple / Court Name & No.) (Temple / Court Location)

_________________________________ ___________________________________

(Telephone Number) (email address)

Registration Fee Includes Desert Hospitality, Luncheon and Ball.

Fees for extra tickets may be paid on this form:

(Special Dietary need - diabetic, vegetarian. Please circle one).

________Desert Hospitality $20 __________ Luncheon $20 ___________ Ball $30

Methods of Payment: Temple/Court Check; Money Order; or Cashier’s Check will be accepted.

Personal Checks will be accepted until May 15, 2010.

MasterCard and Visa credit cards accepted. A $4.00 surcharge will be included for credit card use.

Badges will not be mailed. Must be picked up on site.

Charge My MasterCard Visa

Cardholder’s Name:________________________________ Acct. #________________________________

Exp. Date: _______________ Cardholder’s signature: _________________________________________

Total fees paid today ____________________________

Make checks payable to: NC Desert Conference Gala Days

Return completed form with payment to: Dt. Brenda Tipton (108)

Desert Registrar

P.O. Box 354

Pinetops, NC 27864

252-827-5218

Email: Blkbty082@aol.com

Desert website: http://ncdesert-aeaonms.org

All checks returned by the bank will be subject to a $32 fee in addition to full payment of the balance of the check.

Request for registration refunds must be made in writing. All refund requests will be addressed after June 30, 2010.