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2009 Awakenings and Revivals History Conference Registration

Name:

____________________________________________________________________

Street Address:

____________________________________________________________________

City, State, Zip:

____________________________________________________________________

Email:

____________________________________________________________________

Phone:

____________________________________________________________________

 

 Registration Option

Quantity     
  Total
_______ Conference Fee $35.00 _____________
_______ Conference Fee with Meals $85.00 _____________
_______    Graduate Students' Conference Fee $20.00 _____________
_______ Graduate Students with Meals $70 _____________
_______ Late Conference Fee (after April 5th) Add $10 _____________

 

 
Payment 

 

Total Due:

__________________

Payment may be made by:

   
 

Cash: ____________

 
 

Check: ___________

Check #: __________
 

Credit Card: ______

Which: M/C  ________
 

     Card #: ______________________________

           VISA  _______
 

     Exp. Date: ____________________________

           Disc  ________
 

     Name on card:  ________________________

           Am X  _______

 

     Signature: ____________________________

 

Please complete and print this form and enclose check made payable to
'LU Awakenings and Revivals History Conference,' if applicable, to:  

Liberty University
Attn: History Department
1971 University Blvd.
Lynchburg, VA  24502