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St Louis 2010 Registration (Gold-Package)

Registration Information

Attendee Name

First Name

Last Name

Address/Telephone/E-Mail

Address

City

State Zipcode

Phone

E-Mail

Type of Package

Business Session ONLY ($0)

Basic Package ($99)

Silver Package ($274)

Gold Package ($349)

* All prices are prior to $50 mail-in rebate

Special Dietary Requirements

Attendee Status

This is my first LP National Convention

I am an Elected Official

Delegate Status

I want to be a Voting Delegate

I want to be an Observer

National Membership Certification

I certify that I oppose the initiation of force to achieve political or social goals.

Additional Donation/Payment Verification

$5000

$1000

$500

$250

$100

$25

Other:

Occupation

Employer

Federal law requires political committees to report the name, address, and occupation and employer for each individual whose contributions aggregate in excess of $200 in a calendar year. Political contributions are not tax-deductible.

By checking this box I acknowledge that contributions from corporations and foreign nationals are prohibited. I also acknowledge that this contribution is made on a personal credit or debit card for which I have the legal obligation to pay, and is made neither on a corporate or business entity card nor on the card of another.

Complete this form and select the button above labeled "Submit Registration Calculate Payment Amount" to determine the registration fee due and to receive your temporary registration code prior to payment.

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