Registration

Online Convention Registration Request

First Name *:      

Last Name *:      

Street Address1 :

Street Address 2:

City *:                

Zip Code:            (5 digits)

State:                   State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

State of Origin:     Origin Adamawa Bauchi Benue Borno Gombe Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Nassarawa Niger Plateau Sokoto Taraba Yobe Zamfara FCT-Abuja

Daytime Phone:   

Evening Phone:    

Email *:               

Arrival Date :       

Departure Date :  

Award Banquet

General Dinner Ticket = $75
Member Ticket = $50 each
Corporate Table (10) = $600

Will you be attending the Award Banquet?

Number of Tickets Required :   

Special Needs :           Enter comments here!