Room Rates: Single or Double $109.00 plus taxes (approx. 12%)

Tripple $119.00 or Quad $129.00

May book at (813) 879-4800 or Group Web Page (POG)

 Room reservation cutoff date: March 21, 2012

Workshop Registration Form

Please mail completed registration form by: April 9, 2012

  To: Dorinda Carwell, CDM-CFPP

          PO Box 530008

          St. Petersburg, FL 33747

          Cell: 727-515-5728

*CASH, CHECKS, OR MONEY ORDERS ONLY*

MAKE CHECKS PAYABLE TO FL DIETARY MANAGERS ASSOCIATION (FDMA)

(  ) Member: $120    (  ) Student: $55     (  ) Retired Member: $55 

(  ) Non Member: $130  (   ) 1 Day: $65 What Day:___________________

Name:______________________________ Membership#_________

Address:_________________________________________________

City:_______________________State:________Zip Code__________ 

Will this be your first time attending a ANFP(DMA) seminar? (  )Yes

 (   )No

Facility Name:_____________________________________________

Facility Address:____________________________________________

Email Address______________________________________________

Total amount enclosed: $__________

Service Pin Request:  (   ) Yes    (   ) No 

 Year you became active member of ANFP (DMA) _____