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NC Black Summit 2010 Registration Form
Last Name
MI
Total Amount
Number of Attendees (Including yourself)
Name as show on the Card:
Credit Card Number:
Exp. Date:
Credit Identification Number:
Margherita
Make checks payable to: The NC Alliance of Black Elected Officials P.O. Box 26615 Raleigh, NC 27611
Do you belong to a member organization: (Please check appropriate box)
Are you a member of a support organization: (Please check appropriate box)
First Name
Address
City
State
Zip
Phone Number
Fax Number
Email Address