2020 NASW-Illinois Chapter Virtual Conference - Page 12



RM • RE
O
F
RM • RE
FO
AT
STR ION
I
G
REGISTRATION INFORMATION
NASW Member ID #:_________________________________
PAYMENT INFORMATION
Check the type of payment enclosed:
Check
Visa
MasterCard
Name:_____________________________________________
Card Holder Name:__________________________________
Preferred Pronouns:
He/Him/His
Credit Card #: ______________________________________
She/Her/Hers
They, Them, Theirs
RATION
IST
G
Other: _________________________________________
Exp. Date:_____ Security Code:______ Billing Zip:_________
Job Title:___________________________________________
Cardholder Signature:________________________________
Company:__________________________________________
If requesting an invoice, please send a completed registration
form and include the following: PO # (if applicable); name,
phone number, and e-mail of person who handles invoice
payment; company name; and billing address. You can mail
this to the address on the form or e-mail a scan of all forms
to: » office.naswil@socialworkers.org.
Address:___________________________________________
Address 2:__________________________________________
City:______________________ State:_____ Zip:__________
SAVE TIME
REGISTER ONLINE
Daytime Phone #:____________________________________
E-mail:_____________________________________________
www.naswil.org/conference
If you have a physical or communication need that may affect
your participation in conference activities, please contact the
NASW-Illinois Chapter at least thirty (30) days before the
conference. We cannot ensure the availability of appropriate
accommodations without prior notification of need.
PLEASE NOTE: By registering for the 2020 NASW-Illinois
Chapter Statewide Conference, you are authorizing the use
of any photograph(s), name, and/or likeness in any recorded
sessions for NASW-Illinois Chapter purposes.
TOTAL AMOUNT ENCLOSED:____________________
I have a special physical or communication need and
will contact the NASW-Illinois Chapter at » office.naswil@
socialworkers.org to discuss accommodations no less
than thirty (30) days before the conference date.
12
NASW-ILLINOIS CHAPTER / Thursday, November 19, 2020

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