Registration Form

Registration Form

PBA CIVIL LITIGATION SECTION
HARRISBURG REGIONAL DINNER
Keynote Speaker: Hon. J. Michael Eakin
HARRISBURG HILTON HOTEL AND TOWERS
HARRISBURG, PA
Thursday, November 29, 2012

(Reception begins at 5:30 p.m.)

Credit Card Payment REQUIRED!

Name:
Address:
Supreme Court ID No:
Email:
Phone:

Dinner Entrée Selection (check one):
Filet mignon and lump crab cake combination
Vegetarian option: Vegetarian strudel, herbed orzo, roasted pepper & mango coulis

Please contact PBA if you require any special services including any special dietary requirements/substitutions.

Describe any special service or if you have any dietary requirements.

REGISTRATION FEES - CHECK APPROPRIATE BOX

	PBA Section Member - $50

	Non-section Member - $95

Total Amount Due:

For security reasons,
please enter the following 5 letters
KXWWY
then click the submit button.

To complete the registration process you will need to "Proceed to checkout" in the store and walk through the steps to process your credit card information. For assistance contact Traci Raho at (717) 238-6715, ext. 2255.

Return this form NO LATER THAN November 20, 2012 to:
Christine Dolan
PA Bar Association
P. O. Box 186
Harrisburg, PA 17108