GEORGIA MOOSE ASSOCIATION

MID YEAR CONFERENCE

PRE- REGISTRATION FORM

February 25 - 28, 2010

NAME_______________________       LODGE NAME AND #__________________

MID #________________                         EXPIRATION DATE__________________

PILGRIM_______                                        ADMINISTRATOR_______

FELLOW________                                       GOVERNOR   __________

M/ LEGIONAIRE____                                  PAST GOVERNOR ___________

                                                REGISTRATION FEE                                  $10.00

                         (IF DESIRED)       FELLOWSHIP LUNCH                                 $11.00                                             

TOTALS   PAID           CK# ________                       $__________

REMIT CHECK OR MONEY ORDER TO:  Georgia Moose Association Inc.

                                                                           62 Honey Lane

                                                                           Mc Donough Ga 30252

Pre-registration accepted until February 10th 2010 after which fee is $15.00

Hotel reservations can be made by calling 1 478 / 746 - 1461

                                                REGISTRATION ACCEPTED NOW



PRINT THE ABOVE FORM, FILL-OUT, AND MAIL ALONG WITH YOUR CHECK OR MONEY ORDER.