*Name:
Name on name tag:
Title:
Company:
Address:
City:
State/Province:
Zip/Postal Code:
County:
*Phone:
( )
-
Fax #:
( )
-
*Email:
Who should we contact to thank for your participation?
Name:
Title:
Company:
Address:
City:
State:
Zip/Postal Code:
County:
Phone:
( )
-
Fax #:
( )
-
Email:
Which week do you wish to attend? (Select in order of preference)
Select...
1st Choice
2nd Choice
3rd Choice
4th Choice
Cannot attend
*Week 1: July
7 - 14,
2012 - Lycoming College
Select...
1st Choice
2nd Choice
3rd Choice
4th Choice
Cannot attend
*Week 2: July 14 -
21,
2012 - Lycoming College
Select...
1st Choice
2nd Choice
3rd Choice
4th Choice
Cannot attend
*Week 3: July
28 -
August 4, 2012 -
Lycoming College
Select...
1st Choice
2nd Choice
3rd Choice
4th Choice
Cannot attend
*Week 4: August 4 - 11, 2012
- Penn College
How many years have you served as a company advisor?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
years.
(Include 2012)
*What is you shirt size (polo shirt)?
S
M
L
XL
XXL
XXXL
New Company Advisors:
If this is your first
time as a Company
Advisor, you will be
provided a PFEW polo
shirt from our existing
stock. Colors will be
limited and do not
include the options
available if you choose
to order and pay for
your own shirt. If you
prefer to purchase your
own, you can do so by
clicking here .
Returning Company
Advisors:
All Volunteers can
now purchase their own
polo shirt by filling
out the
CA Shirt Order Form .
If you choose not to
purchase a shirt, please
be sure to bring a PFEW
polo shirt that you
received from one of
your previous years of
service.
*Which training session do you plan on attending?
Unable to attend any session
May 25 (Erie)
June
1 (King of Prussia)
*What are your lodging plans?
I will make a reservation at the Holiday Inn.
I want to stay on campus.
I live locally and do not need other accommodations.
*Would you be willing to serve as a speaker?
Yes
No
Potential Speaking Topics
GENERAL RELEASE FOR USE OF PICTURES AND QUOTATIONS
I hereby consent to the publication and use by PFEW of my name, biographical data, quotations or written or
verbal statements about PFEW, and any official photographs taken by the PFEW staff for publicity and promotion
of the PFEW program. Further, I give permission for my picture to appear on a PFEW Web Page and promotional
video. (Pictures and names for the web page will only be used for promotional purposes and are simply snapshots
that are taken during the program. No other identifying information will be published.)
By typing my full name below, I am agreeing to the terms above and understand that this “electronic signature”
is binding as would be a handwritten signature.
*(type your full name)
*(date)