Suffolk County Bar Association Event Registration Form

To be used by attorneys who wish to register for Bar Association Events

Suffolk County Bar Association requests that you to complete the following form so that we may register you for events you have selected. Please note that the information contained herein is transmitted to us through a secure site. If you have any questions you may contact us:
(631) 234-5511 (ext. 230), or E-Mail us at events@scba.org

Date of Request *: Please use mm/dd/yy format
Name (full name [first & last])*:
E-mail Address*:
Address where we can contact you *:Street address:

City: State: Zip:

Work Phone (include area code)*:
Home Phone (include area code):
Cell Phone (include area code):
Fax (include area code):
I wish to be notified of future events by e-mail.Yes       No
My membership status is: *SCBA Attorney member ,      SCBA Student member ,     Non-Member Attorney
Event(s) you wish to register or RSVP for:(choose as many as you wish, by clicking on each choice while pressing the Ctrl key - scroll to see all choices)*
The number of people (persons) attending the event is (default is 1, update as required)*:

Please enter the names of all persons attending this event *.

If you have chosen more than one event, please indicate who will be attending which event.

The total amount due is  (If no charge or amount is due please enter 0)*:  

Method of payment:
 

Credit Card information:

Charge card type (choose one):

American Express (AMEX) ,    Master Charge ,     Visa,    Discover

Account #             Expiration : (Please use mm/yy format)

I hereby authorize the Suffolk County Bar Association to charge the above total to my credit card account *: