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Registration form
Registration form
NYSAPLS Spring Workshops 2022
NY SAPLS Spring W orkshops 2022
Register online today at www.nysapls.org or complete the form below and submit with payment by mail
R egister online today at www .nysapls.org or complete the form belo w and submit with payment b y mail
NAME:_____________________________________________________________________________________________
NAME: _____________________________________________________________________________________________
TION
A
:
__________________________________________________________________________________
GANIZ
OR
ORGANIZATION: __________________________________________________________________________________
ADDRESS: _________________________________________________________________________________________ _________________________________________________________________________________________
ADDRESS:
:
______________
I
P
_________________________________________________________
Y
:
S
__________ Z
A
T
E
:
CIT
CITY: _________________________________________________________STATE: __________ ZIP: ______________
T
(this is my
(this is my *home/*work address)*home/*work address)
ORK
P
HONE
:
:
HOME
HONE
P
_______________________________
__________________________________
WORK PHONE: _______________________________ HOME PHONE: __________________________________
W
E-MAIL: _________________________________________________________________
_________________________________________________________________
E-MAIL:
NYS LS LICENSE NUMBER: _____________________________________________________ _____________________________________________________
NYS LS LICENSE NUMBER: Register Online!
Save time &
Save time &
Register Online!
W or kshop fees: www.nysapls.org
Workshop fees:
www.nysapls.org
F ee includes instr uction, digital handouts, lunch and morning/afternoon r efr eshments.
Fee includes instruction, digital handouts, lunch and morning/afternoon refreshments.
NYSAPLS Members
NYSAPLS M embers NYSAPLS M embers N on-M embers
Non-Members
NYSAPLS Members
on-licensed)
(N
(Licensed) (Non-licensed)
(Licensed)
“Early B
” R
$
“Early B
9
“Early Bird” Registration*: $349
9
ir
d
egistration*:
“Early Bird” Registration*: $249 “Early Bird” Registration*: $199 “Early B ir d ” R egistration*: $ 3 4 9
” R
1
ir
egistration*: $249
d
R egular Rate: $299 R egular Rate: $249 R egular Rate: $399
Regular Rate: $299
Regular Rate: $399
Regular Rate: $249
* To qualify for “Early Bird” registration rates, your payment must be received 30 days prior to the event date.
* T o qualify for “Early B ir d ” r egistration rates, y our payment must be r eceiv ed 30 days prior to the ev ent date.
ch 30th – F
W
(B
ebster)
y A
pril 4th –
y M
(By March 30th – Fishkill; by April 4th – Webster)
ar
ishkill; b
, NY
A
pril 20 – F
NYSAPLS M
ask P
ebster
ishkill, NY
W
olicy:**
Choose location: April 20 – Fishkill, NY May 4 – Webster, NY NYSAPLS Mask Policy:**
M
ay 4 –
Choose location:
w
or
Y
New York is currently experiencing
ently experiencing
e
k is curr
N
ptions:
Payment Options: a significant incr ease in Cor onavir us
ayment O
P
a significant increase in Coronavirus
infections, including the Delta variant.
Check enclosed (make payable to NYSAPLS Inc.) infections, including the D elta v ariant.
nc.)
Check enclosed (make payable to NYSAPLS I
The CDC currently recommends that fully
The CDC curr ently r ecommends that fully
educe their
accinated people can fur
ther r
Credit card v vaccinated people can further reduce their
Credit card __ MC __ Visa __ Amex __ Discover __ MC __ Visa __ Amex __ Discover
risk of becoming infected with the D
risk of becoming infected with the Delta
elta
Credit card number: _____________________________________________________ variant and transmitting it to others by variant and transmitting it to others by
Credit card number: _____________________________________________________
wearing a mask in public indoor settings
w
earing a mask in public indoor settings
_
ate: ___/___ S
_
_
in areas of substantial or high community
_
xp
_
_
_
. D
_
Exp. Date: ___/___ Security Code: __________ in ar eas of substantial or high community
E
_
ecurity Code: _
transmission. I
transmission. In an abundance of caution,
n an abundance of caution,
Signature:
NYSAPLS has decided to follow the CDC
Signature: _____________________________________________________________ _____________________________________________________________ NYSAPLS has decided to follo w the CDC
ent. Ther
ev
ecommendations at our
e,
efor
r recommendations at our event. Therefore,
illing A
ess:
Billing Address: _________________________________________________________ w earing a mask o v er y our nose and mouth
wearing a mask over your nose and mouth
_________________________________________________________
B
ddr
will be mandatory for all attendees and staff.
will be mandator y for all attendees and staff.
, NY 12210
Mail this form to: NYSAPLS, 146 Washington Avenue, Albany, NY 12210 D isposable masks will be pr o vided at the
ashington A
W
enue, Albany
v
ail this for
M
m to: NYSAPLS, 146
Disposable masks will be provided at the
ou do not hav
ev
event if you do not have your own.
wn.
e y
our o
ent if y
Questions?
Q uestions?
** Subject to change with current guidelines Subject to change with current guidelines
Please call, (518) 432-4046 • Fax (518) 432-4055 or email, info@nysapls.org **
ax (518) 432-4055 or email, info@nysapls.org
lease call, (518) 432-4046 • F
P
as of event date.
as of ev ent date.
Y
otect
egistration*
our R
r
NEW! Option to Protect Your Registration*
NE
ption to P
W! O
w offer cancellation insurance thr
d par
ailable b
vider
o
e no
We now offer cancellation insurance through Allianz Global Assistance, a third party provider. The insurance is ONLY available by registering
ty pr
W
y r
egistering
lobal Assistance, a thir
. The insurance is ONL
Y av
ough Allianz G
.nysapls.org for mor
ent on our w
for this event on our website with a credit card payment. Register online at www.nysapls.org for more details.
egister online at www
d payment. R
for this ev
edit car
e details.
ebsite with a cr
NYSAPLS C
NYSAPLS Cancellation Policy:
ancellation P
olicy:
Payment must be made in full upon registration. Purchase orders not accepted. Cancellations submitted in writing 30 days or more prior to
P ayment must be made in full upon r egistration. P ur chase or ders not accepted. Cancellations submitted in writing 30 days or mor e prior to
the ev ent, will be granted a 100% r efund, less a 10% pr ocessing fee. After the 30 day windo w , I understand that my ev ent ticket pur chase is
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
ent, r
efundable unless I obtain the cancellation
v
e, 0-29 days prior to the ev
efor
eser
egistration fees ar
intended to hold my r
intended to hold my reservation. Therefore, 0-29 days prior to the event, registration fees are non-refundable unless I obtain the cancellation
e non-r
ation. Ther
e details.
.nysapls.org for mor
d par
lobal Assistance, a thir
o
ty pr
y Allianz G
insurance pr
insurance provided by Allianz Global Assistance, a third party provider, during checkout. Register online at www.nysapls.org for more details.
vided b
o
egister online at www
, during checkout. R
vider
egistrants to advise us of any disability and any r
e invite all r
I 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
equests for
dance with
n accor
T
isabilities A
ct, w
itle III of the Americans with D
accommodations to that disability . I f y ou hav e any questions, please call the NYSAPLS office at 518-432-4046.
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.
B
e an option to obtain cancellation insurance.
wledge the cancellation policy abo
y submitting this form, I ackno
v
e and understand I do not hav
_________________________________________________________________________________________________________
*Signature:
*Signature: _________________________________________________________________________________________________________
EMPIRE STATE SURVEYOR / VOL. 57 • NO 6/ 2021 • NOVEMBER/DECEMBER 23
