CECA Convention Registration Form Name* First Last Spouse/Guest Name First Last Company Name* Lifetime Members, please put Lifetime Member or the company from which you retired.Mailing Address* Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* PhoneHIDDEN-Please provide the number of children attending with you so we have an accurate headcount:Please enter a number greater than or equal to 0.Registration FeesRegistration Type: IF YOUR SPOUSE (OR A GUEST) IS ATTENDING - CHOOSE COUPLE REGISTRATION$379 Couple -CECA Member$329 Individual CECA Member$400 Individual Non-Member$500 Couple Non-MemberGolfGolf is $150 per player. Golf will be straight Captain’s Choice, so you may send us your team or we will be glad to put you on a team.Number of Participants for Golf Event - Pine Lakes Course01234If you have put together your golf team, please list your team members names here or you can email Kendall with your team later:1st Golfer's Name First Last 1st Golfer's Handicap2nd Golfer's Name First Last 2nd Golfer's HandicapTotal Price for Golfer(s) Price: $63.00 Brunch and Painting ClassSpouse Tour – Painting in Paradise - Brunch and Painting Class Adult to attend Brunch and Painting Class Price: $140.00 Quantity: ages 19 and up will be considered an AdultAdult Name to attend Brunch and Painting Class First Last CornholeCorn Hole Tournament Registration:NoneOne PlayerOne Team$10 a player or $20 a team.Name of First Corn Hole player First Last Name of Second Corn Hole player First Last I would like to have my logo on the CECA Convention T-shirts for $144:No, do not include my logo on the T-ShirtYes, please include my logo on the T-ShirtEach Registrant and Spouse/Guest will receive a Convention T-Shirt. Those who would like to be a sponsor the shirts will have their company logo on the back of the shirt. Only one person from a company should sign up for this. This sponsorship opportunity is for CECA Members Only. To have your company logo included on the t-shirts, you must sign up by May 20th. Logo I have sponsored the shirt in the past and you have my logo I will send my logo to kparker@carolinaseca.org SponsorshipI would like to be a Sponsor of the CECA Convention:No SponsorshipPlatinum Level - $5000Gold Level - $1000Silver Level - $500Bronze Level - $250Other AmountOther Amount T-Shirt Sizes - Each Registrant and Spouse/Guest receive a Convention T-ShirtYour T-shirt Size:SmallMediumLargeExtra LargeXXL3XL4XLSpouse/Guest Shirt SizeNoneSmallMediumLargeExtra LargeXXL3XL4XLBilling InformationPlease make sure the following information is as it appears on the credit card statement to ensure proper billing.Billing Amount: $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name CANCELLATION POLICY: Full Refund prior to May 24th; $100 Service Charge, May 25th - June 1st; No Refunds after June 1. Additional Notes (Anything that you need to tell us about your registration).PhoneThis field is for validation purposes and should be left unchanged.
