Registration information:

Full Name:
Maiden Name:
Mailing address:
Address (cont.):
Address (cont.):
City:
State:
Zip Code:
TTY:
VP:
FAX:
Voice:
Text:
E-mail:

Do you wish to have your name and e-mail listed publicly or private? Publicly Private

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For staff:

Year worked from:   --- select --- 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020   to:   --- select --- 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

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For student:

Year graduated:   --- select --- 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

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Credit Card Payment



NOTE: Deadline is on or before June 15, 2020!

How many people?  

  --- select below ---     1 people - $75.00     2 people - $150.00     3 people - $225.00     4 people - $300.00     5 people - $375.00  

Please select Delicious Menu:   California Chicken    Vegetarian Chicken

Easy Payment Plan: $25.00 per month X 3 months = $75.00/per person   --- select below ---     1 of 3 payments - $25.00     2 of 3 payments - $25.00     3 of 3 payments - $25.00   NOTE: If you are planning to pay in full at once, then skip this optional section and proceed to below.

Credit Card Info:

MasterCard

Visa

Card Holder Name:

Card Number:

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Expiration Date:

01 - Jan 02 - Feb 03 - Mar 04 - Apr 05 - May 06 - Jun 07 - Jul 08 - Aug 09 - Sep 10 - Oct 11 - Nov 12 - Dec

20 - 2020 21 - 2021 22 - 2022 23 - 2023 24 - 2024 25 - 2025 26 - 2026 27 - 2027 28 - 2028 29 - 2029 30 - 2030

3-digit security code:

Note: After the card is charged, the name "DEAFWORKS" will appear on your billing statement.

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Comments:

(Please send ONCE and await for confirmation page after submittal)