Wufoo

SELECT THE DISTRICT MEETING YOU PLAN TO ATTEND. You can attend only one (1) meeting and you must register in advance. *
Monday, Sept. 10, 2018 - WINSTON SALEM - Benton Convention Center Tuesday, Sept. 11, 2018 - GREENSBORO - Greensboro Marriott Downtown Wednesday, Sept. 12, 2018 - BLOWING ROCK - Meadowbrook Inn Thursday, Sept. 13, 2018 - ASHEBORO - AVS Catering & Banquet Center Tuesday, Sept. 25, 2018 - WELDON - The Centre at Halifax Community College Wednesday, Sept. 26 2018 - ROCKY MOUNT - Nash Community College
MEMBER - First Name *
MEMBER - Middle Initial *
MEMBER - Last Name *
Preferred First Name (For your Badge) *
MEMBER - Check One: *
I am a state retiree/or retired teacher I am a local government retiree
Address (Member) *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Email Address *
Will you bring a SPOUSE/GUEST? *
Yes. If yes, please complete the information requested below. No
SPOUSE/GUEST First Name
SPOUSE/GUEST Middle Initial
SPOUSE/GUEST Last Name
Preferred First Name for Your Spouse/Guest's Badge
SPOUSE/GUEST Address (Leave blank, if same)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
SPOUSE/GUEST Name (Check one)
Spouse/guest - not a state or local government retiree Spouse/guest - is a state retiree or retired teacher Spouse/guest - is a local government retiree
Do Not Fill This Out