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CPAFMA Indiana Event Registration Form

Indiana Chapter Meeting
May 17, 2019
Indiana CPA Society
900 E. 96th Street, #250
Indianapolis, IN
Contact Name: Jeremy Cole, CPA, CGMA
(317) 472-2148
jcole@somersetcpas.com
Cost(s): $45.00 Member / $45.00 Non-Member

Name:   
Title:   
Company:   
Address:   
City:   
   State:     Zip:  
Country:
Phone:   
Email:   
*Guest Name(s):   
*Note: Only enter guest names if event includes an appropriate registration type/fee option below. If event does not have separate guest/spouse registration options, you must register and pay for each person seperately.
 
Registration Type/Fee(s) - Please Select:
Member ($45.00)
Non-Member ($45.00)

Billing Information:    Same as Above
Name:
Company:
Address:
City:    State:    Zip:
Country:
Telephone:

Payment Information
Payment Type:   Visa    Mastercard    American Express    Invoice Me   
Will Bring Check   
Card Number:       Expiration Date:      
CVV2 Code:    3 or 4 digit code on the back or front of your card.
Name on Card:   
 
Comments or Questions: