REGISTRATION FORM REGISTER ONLINE - appa-net.org

1 REGISTRATION form . APPA 43RD ANNUAL TRAINING INSTITUTE JULY 29 - AUGUST 1, 2018 PHILADELPHIA, PA. REGISTER ONLINE . Please use a photocopy of this form for each registrant. Please print clearly. MAIL. APPA Institute First Name:_____Last Name:_____ c/o The Council of State Governments 1776 Avenue of the States, Lexington, KY 40511. Title:_____ Email:_____. Address:_____. PHONE. (location where confirmation should be sent) City:_____ State:_____Zip:_____. FAX. Phone:_____ Fax:_____ To better plan Institute workshops and Agency/Organization:_____ activities, please supply us with the r Check if same address as above following information.

2 Agency/Organization Address:_____ LENGTH OF EXPERIENCE IN CORRECTIONS. Less than 2 years 16-20 years Agency/Organization City:_____ State:_____ Zip:_____ 2-5 years 21-25 years 6-10 years More than 26 years Agency/Organization Phone:_____ Fax:_____ 11-15 years Agency/Organization Email:_____ GENDER Male Female 1 year 3 year RACE/ETHNICITY. APPA MEMBERSHIP $50 $135 $_____ African American Native American/. 301-085-10-11180-40010 Caucasian Alaska Native One year of individual membership. New Member Renewal Hispanic Asian Other REGISTRATION Includes general sessions, exhibit receptions and workshops.

3 (All fees are per person.). HIGHEST LEVEL OF EDUCATION. On or Before 06/28/18 After 06/28/18. Graduate Equivalency Diploma(GED). Member of APPA $355 $415 $_____ High School Diploma Non-Member $415 $475 $_____ Associate's Degree Student $200 $200 $_____ Bachelor's Degree Master's Degree If you are not a member of APPA, you are required to pay the regular REGISTRATION fee. Memberships will be verified. Doctorate SINGLE DAY REGISTRATION $230 $230 $_____ GEOGRAPHICAL AREA. Single Day REGISTRATION includes all sessions, workshops, and exhibit hall entrance for entire day.

4 Urban (pop. over 50,000). Single day rate is good for ONLY ONE of the days listed. Rural (pop. under 50,000). Specify Day: r Monday, July 30 r Tuesday, July 31. JOB JURISDICTION. Judicial INTENSIVE SESSIONS $50 $50 $_____ Federal Available only to registrants of Institute. Attendance at intensive sessions only is not permitted. State Specify Intensive Session Title _____. County City GUEST REGISTRATION $230 $230 $_____ Private firm/business This rate is available to immediate family members not employed in the corrections field. Academic Institution Allows entry into general sessions, breaks, exhibit receptions, and workshops.

5 Province Guest's name_____ Nonprofit organization Organization_____ Tribal/Alaskan Village Other_____. City_ _____ State_____. PRIMARY WORK AREA. COMMUNITY CORRECTIONS CHASE NO FEE NO FEE _____ Juvenile Probation & Parole An INTERACTIVE training session. Limited space - only 100 spaces available! Adult Probation & Parole Adult Probation Adult Parole GRAND TOTAL $_____. Juvenile Probation 300-085-11-12207-43000. Juvenile Parole/Aftercare Residential PAYMENT Non - Residential Treatment Provider Check Enclosed Government Purchase Order Enclosed; PO #_ _____ Academia Charge to: VISA MasterCard American Express Tribal Issues Other_____.

6 Cardholder's Name_____. PROFESSIONAL CATEGORY. Card Number:_____ Line Personnel Attorney V code:_____ Expiration Date:_____ Commissioner/ Educator/. Director/Chief Researcher Signature:_____ Date:_____ Administrator Private Sector/. Consultant Corporate Trainer Retired SPECIAL ASSISTANCE Parole Board Student Please list any dietary restrictions or special needs that you might require under the American Disabilities Act. Member Other Attach a written description of needs. Judge APPA FEDERAL ID # 56-1150454. CONFIRMATION/REFUND POLICY. A full refund, less a $50 processing fee, is available until July 8, 2018.

7 No refunds are available after July 8, 2018. In order to receive a refund, written requests must be sent to the APPA Institute, c/o The Council of State Governments, 701 E. 22nd Street, Suite 110, Lombard, IL 60148 or faxed to All requests for refunds must be postmarked or faxed by July 8, 2018.