CCNA XXXI Quebec Pre-Registration Credit Card

Please use this form to register for CCNA being held in Saint-Hyacinthe, Quebec. This form uses Credit Card for payment. There is a small fee built into the price to cover online processing fees.

If you prefer to pay for your registration by email money transfer please click here

1First Registrant > 2Second Registrant > 3Review > 4Payment
Email Confirmation Sent
Have you previously made a purchase from CCNA XXXI and now making additional purchases? *

Have you previously made a purchase from CCNA XXXI and now making additional purchases? No, I have not registered Yes, I have registered previously
Registrant

Complete this section for the first registrant (there is a section for a second registrant on the next page if you select the option to add another registrant)
Name Name * First Last
Though this is an anonymous program, your full name would be very helpful in processing your registration
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Email *
Would like to have your email address added to our mailing list to receive convention updates? *

Would like to have your email address added to our mailing list to receive convention updates? Yes No
Clean Date Clean Date / MM / DD YYYY
Are you interested in serving?

Are you interested in serving? Speaker (minimum 3 years clean) Chair Person (minimum 2 year clean) Sub Committee (clean time requirement will be determined)
Select your package or items from below.

Pre-Registration Full Package includes everything listed below.

You may also purchase multiple Basic Pre-Registrations to distribute yourself at a later date.

Pre-Registrations are only available for purchase until Aug 13, 2023

*

Select your package or items from below.

Pre-Registration Full Package includes everything listed below.

You may also purchase multiple Basic Pre-Registrations to distribute yourself at a later date.

Pre-Registrations are only available for purchase until Aug 13, 2023

Pre-Registration Full Package-$171.60 Pre-Registration Registration - $41.60 2 Pre-Registrations - $ 83.20 3 Pre-Registrations - $ 124.80 4 Pre-Registrations - $ 166.40 5 Pre-Registrations - $ 208.00 Comedy Show-$20.80 Saturday Banquet - $62.40 Saturday Dance - $15.60 Sunday Breakfast - $31.20

Pre-Registration Full Package includes everything listed below.

You may also purchase multiple Basic Pre-Registrations to distribute yourself at a later date.

Pre-Registrations are only available for purchase until Aug 13, 2023
In an effort to provide an alternative you are welcome to request a vegetarian or a vegan meal. Do you wish to request a special meal at the banquet?

In an effort to provide an alternative you are welcome to request a vegetarian or a vegan meal. Do you wish to request a special meal at the banquet?

Regular Meal Vegan Option Vegetarian Option
New Comer Contribution ($30.00 will purchase a basic package for a new comer but donations of any and all values are appreciated) $ Dollars . Cents
Monies collected through this process are used to assist those who cannot afford a registration package. Early Bird Basic Registration is $30.00. Please contribute any dollar amount you can.
Do you wish to add a second registrant? *

Do you wish to add a second registrant? Yes No
I understand and agree there are no refunds *

I understand and agree there are no refunds Yes
C$0

Total

CCNA XXXI Quebec Pre-Registration Credit Card

CCNA XXXI Quebec Pre-Registration Credit Card

Registrant

C$0

Total

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