* denotes required field

*Name:


*Company:


*Street Address:


*City:

* State:   * Zip:


*Phone:                                 Fax:
  

* E-mail Address:

*Your Business Industry (ie. Banking, Financial Services, Graphic Design, Real Estate):

*Top 5 Industries You Would Like to Meet (ie. Banking, Financial Services, Graphic Design, Real Estate):

1)

2)

3)

4)

5)

TO REGISTER, PLEASE CHOOSE THE APPROPRIATE BOX

NORTH SHORE CHAMBER MEMBER - $25/Ticket

NON-MEMBER - $50/Ticket (must prepay by Credit Card)

PAYMENT -(Non-member: Payment by Mastercard, Visa, AMEX only) non-refundable, but transferable*

Because Specific Space is Reserved, You must cancel within 3 Business Days prior to the Event.

INVOICE ME (MEMBERS ONLY)

VISA:


MC:


AmEx:


Card Number:


Exp Date:

Comments:

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