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Registration form

NYSAPLS Fall Workshops 2021
Register online today at www.nysapls.org or complete the form below and submit with payment by mail
NAME:_____________________________________________________________________________________________

ORGANIZATION: __________________________________________________________________________________

ADDRESS: _________________________________________________________________________________________
CITY: _________________________________________________________STATE: __________ ZIP: ______________
(this is my *home/*work address)

WORK PHONE: _______________________________ HOME PHONE: __________________________________
E-MAIL: _________________________________________________________________

NYS LS LICENSE NUMBER: _____________________________________________________ Register Online!
Save time &
Save time &
Register Online!
Workshop fees: www.nysapls.org
www.nysapls.org
Fee includes instruction, digital handouts, lunch and morning/afternoon refreshments.
NYSAPLS Members NYSAPLS Members Non-Members
(licensed) (Non-licensed)

 By September 27: $249  By September 27: $199  By September 27: $349
 After September 27: $299  After September 27: $249  After September 27: $399

Choose location:  October 6 – Webster, NY  October 13 – Fishkill, NY NYSAPLS Mask Policy:
New York is currently experiencing
Payment Options: a significant increase in Coronavirus
 Check enclosed (make payable to NYSAPLS Inc.) infections, including the Delta variant.
The CDC currently recommends
 Credit card __ MC __ Visa __ Amex __ Discover that fully vaccinated people can
further reduce their risk of becoming
Credit card number: _____________________________________________________ infected with the Delta variant and
transmitting it to others by wearing
Exp. Date: ___/___ Security Code: __________ a mask in public indoor settings in
areas of substantial or high community
Signature: _____________________________________________________________ transmission. In an abundance of
caution, NYSAPLS has decided to follow
Billing Address: _________________________________________________________ the CDC recommendations at our event.
Therefore, wearing a mask over your
Mail this form to: NYSAPLS, 146 Washington Avenue, Albany, NY 12210 nose and mouth will be mandatory for
Questions? all attendees and staff. Disposable masks
will be provided at the event if you do
Please call, (518) 432-4046 • Fax (518) 432-4055 or email, info@nysapls.org not have your own.
NEW! Option to Protect Your Registration*
We now offer cancellation insurance through Allianz Global Assistance, a third party provider. The insurance is ONLY available by registering
for this event on our website with a credit card payment. Register online at www.nysapls.org for more details.

NYSAPLS Cancellation Policy:
Payment must be made in full upon registration. Purchase orders not accepted. Cancellations submitted in writing 30 days or more prior to
the event, will be granted a 100% refund, less a 10% processing fee. After the 30 day window, I understand that my event ticket purchase is
intended to hold my reservation. Therefore, 0-29 days prior to the event, registration fees are non-refundable unless I obtain the cancellation
insurance provided by Allianz Global Assistance, a third party provider, during checkout. Register online at www.nysapls.org for more details.
In accordance with Title III of the Americans with Disabilities Act, we invite all registrants to advise us of any disability and any requests for
accommodations to that disability. If you have any questions, please call the NYSAPLS office at 518-432-4046.

By submitting this form, I acknowledge the cancellation policy above and understand I do not have an option to obtain cancellation insurance.

*Signature: _________________________________________________________________________________________________________

EMPIRE STATE SURVEYOR / VOL. 57 • NO 5/ 2021 • SEPTEMBER/OCTOBER 25