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| Official Registration Form |
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District Convention
September 24-25, 2010 - Pensacola, Florida |
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Name (Civitan) ___________________________________________________
Name for Badge _________________________________________________
Address ________________________________________________________
City ___________________________ State ________ Zip Code ___________
Spouse or Guest (non-Civitan) _______________________________________
Phone: ___________________________________________
Email: ____________________________________________
Club Delegate? Yes ______ No ______
Please circle the office(s) you currently hold:
• Past International President
• International Board Member
• District Governor
• Past District Governor
• District Officer or District Director
• District Lt Governor
• District Committee Chairperson
• Club President
• Club President-Elect
• Club Secretary
• Club Treasurer
Please make check payable to: Alabama-West Florida District
Send registration form and fees to:
Meg Smith,
Secretary/Treasurer
2838 Colonial Drive
Montgomery, AL 36111
If you have any questions, please call Meg Smith at: 334-398-2838 |
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