Name:

Street/Appartment Address:

City:

State:

2010-Workshop Option 1, 2, or 3:

Date & Site of your CPNE:

Date of a scheduled workshop you want to attend:

Alternate Dates you would consider taking if one was added (Additional dates may be added):

Copy and Paste this form to an email, fill it out and send it to necpneworkshop@yahoo.com