CONFERENCE REGISTRATION FORM

Name: _______________________________________________________

Address: _____________________________________________________

City: ______________________________ STATE ________________

ZIP _________________

Representing? ______________________________

Title: _____________________________________

Lodge: ___________________________________

Chapter: _________________________________

Council: __________________________________

Commandery: ______________________________

Will your lady attend? Yes: [ ] No: [ ]

Her name? ______________________________________

Any dietary restrictions? ____________________________________________________________

Other: __________________________________________________________________________

Please detach and return with the registration fee of $35.00 per person to:

Emory J. Ferguson 1615 Lakeview Drive NW

Cullman, Alabama 35055-2315

Phone: 256/734-6787