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ASA Legislative Conference 2023 Registration Form
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Email
*
Your email
ASA Member?
*
Yes
No
If yes, what is your ASA Number?
Your answer
Salutation
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Dr.
Mr.
Mrs.
Ms.
Prof.
First Name
*
Your answer
Last Name
*
Your answer
Degree(s)
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Badge Name
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Title
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Phone
*
Your answer
Facility
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Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Country
*
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Payment
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$325 Legislative Conference Member Registration
$150 Legislative Conference Resident Registration
Required
Is this your first time attending the WLC?
*
Yes
No
Other:
Do you require any special ADA requirements? If so, please indicate in the box below:
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Please indicate any dietary restrictions:
Gluten Free
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Vegan
Vegetarian
Food Allergy
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