BOARD OF DIRECTORS

^{ASSE - SPALW NOVEMBER 18
CONFERENCE
REGISTRATION FORM:

Fax Registration:

^{(626) 914 - 7275}
Mail:   LA
ASSE - Dept. W

P.O. Box 3456

San Dimas">

^{ASSE - SPALW NOVEMBER 18
CONFERENCE
REGISTRATION FORM:

Fax Registration:

^{(626) 914 - 7275}
Mail:   LA
ASSE - Dept. W

P.O. Box 3456

San Dimas">

^{ASSE - SPALW NOVEMBER 18
CONFERENCE
REGISTRATION FORM:

Fax Registration:

^{(626) 914 - 7275}
Mail:   LA
ASSE - Dept. W

P.O. Box 3456

San Dimas">

^{ASSE - SPALW NOVEMBER 18
CONFERENCE
REGISTRATION FORM:

Fax Registration:

^{(626) 914 - 7275}
Mail:   LA
ASSE - Dept. W

P.O. Box 3456

San Dimas, CA 91773

r Yes! Register me for the
"Safety for Latinos in the Workplace Conference"

Individual Prices: $ 60 EARLY BIRD DISCOUNT
REGISTRATION (Pre-Paid by
October 28)

$ 75 Registration (Paid Between October 29 to November
17)
$ 85 Walk-in at the door (November 18)

^{$ 35 Full Time Student Registration (anytime)}

Group Price: $ 55 Each for 3 or more from same company
Paid by November 17

Name:
_________________________________________________________________________
Additional Name(s):
____________________________________________________________________________

Company:
_______________________________________________________________________
My Industry: rContractor
rAgriculture/
Landscape rHospitality/Service
rManufacturing

rPublic Agency ^rRetail
rOther
/ NOC

Address: ______________________________ City: _ Zip: __________

Telephone: ______________________________ FAX:
____________________________________

E-Mail: __________________________________________________________ (please
print clearly)
Menu Choices for Lunch: r
HALIBUT r NY STEAK

Please make check payable to “ASSE-Los Angeles” and mail check to
address at top of this form:

r I have enclosed $ _________ r
I will be mailing in $ __________ for the above attendee(s).

UPON PAYMENT YOU WILL RECEIVE AN E-MAIL CONFIRMATION OF YOUR
REGISTRATION

(Notice: A $25 cancellation fee applies within 24 hours of the event)}}}}