ENCorps Summit 2012 Registration

Name, Address, & Reservation

33% of survey complete.

Sending in your registration form as soon as possible will help us prepare and ensure your needs are met
while at the Summit. Please complete the registration form individually even if you are attending with a
significant other. After we receive your completed registration form, we will be in contact with more details
as the Summit draws closer. We are looking forward to seeing you at the Summit on May 21-22, and we
hope you are looking forward to the Summit as well. Thank you and see you soon!

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* 1. Complete Mailing Address:

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address:

Phone Number:

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* 2. Are you currently an Encore Leadership Corps (ENCorps) member?

Yes

No *If you are not currently an ENCorps member, please apply for membership no later than May 1, 2012. To apply visit www.encoreleaders.org.*

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* 3. Will you be attending the Summit on Monday, May 21st and Tuesday, May 22nd?

I am attending the 2012 Summit both days.

I am only attending the first day, Monday, May 21st.

I am only attending the second day, Tuesday, May 22nd.

Other (please specify)

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* 4. This year we are providing handouts in paper and electronic format. Please indicate which option you would like.

Paper format/binder

Electronic flash drive for your computer

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* 5. Do you plan to attend our Cocktails & Hors d’oeuvres Reception on Sunday May 20th?

Yes