REGISTRATION FORM

Workers' Compensation Breakfast Seminar 2024 • Tuesday, January 16, 2024 - 3:30 AM

(Early-Bird price before Monday, January 8, 2024) • DSB01162024WORKE1

Location:

Riverfront Events - Hyatt

Registration Type:

$215.00 - Early Bird Member $215.00 - Member $195.00 - Early Bird Gov/SFSP $195.00 - Gov/SFSP $195.00 - Early Bird Affiliated Profs $195.00 - Affiliated Professionals

PA Credit - Add $13.00 : PA ID No.
The full name of the registrant
Your Delaware ID Number (Bar ID)
The voice phone of the registrant
The employer or firm of the registrant
The employer or firm address of the registrant
The total payment submitted with this form

Please make checks payable to DSBA

Credit Card
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Signature (Required for credit card purchases):

General Information

Return registration form to Delaware State Bar Association, 704 N. King St., Suite 110, Wilmington, Delaware 19801, or by fax to (302) 658-5212. A confirmation will be emailed to the registrant. Please keep a copy of this form as your receipt. CANCELLATION POLICY: Registrants may receive a full refund less a $25 cancellation fee for live seminars, if request is made in writing and received no later than one week prior to the seminar. PA CLE Credit will be reported according to the PA CLE Board rules: www. pacle. org. Unpaid registrants who fail to attend are responsible for the full cost of the live seminar. A registration for a live seminar may be transferred to another attorney. Call DSBA at (302) 658-5279 for more information. Visit www.dsba.org for all seminar policies.

For Office Use Only

YOU CAN FAX THIS FORM TO DSBA:  (302) 658-5212.

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