SELACO Alumni Association
Reunion 2020 Registration
  Registration Information:

  Full Name:_________________________________________________________________

  Maiden Name:______________________________________________________________

  Mailing address: ____________________________________________________________

  City:_________________________________  State:_____________  Zip:______________

  TTY:__________________________  VP:__________________________

  FAX:__________________________  Voice:__________________________

  E-mail:___________________________________________________________________

  Do you wish to have your name and e-mail listed? Publicly  _______ Private  ________

  For staff:

  Year worked from:  _____________________  to  _____________________

  For Student:

  Year graduated:_____________________

  Payment:

  How many people?  ____________

(Deadline is on or before June 15, 2020!)
1 - $75.00
2 - $150.00
3 - $225.00
4 - $300.00
5 - $375.00

Please select Delicious Chicken Menu:  California  _________  Vegetarian  _________



Credit card:  Master Card  _________  Visa:   _________


Card Holder Name:____________________________________________________

Card Number:_____________-______________-______________-___________

Expiration Date:______________/________________    CVV:____________

Signature:___________________________________________________________

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



Mail this form to:
SELACO Alumni Association
P.O.Box 1265
Provo, UT 84603-1265

Web: https://www.selaco.org