CHARTA Spring Conference
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"Retooling For The 21st Century"

April, 26, 2000 8:30am.-4:15pm.

Registration Form
Northern Virginia Mental Health Institute
Falls Church, Virginia

(print out this form and complete)

Name: _______________________ Organization: ________________________

Home Address: _________________________________ City _______________

State _____ Zip ________

Telephone: (H) ___________________ (W) _____________________

FAX _______________________

E-Mail _____________________________

Primary Population Served __________________________

Type of Participant Fee

Current Charta Member $ 25.00

Joining Member $ 55.00

Current Charta Student Member $ 10.00

Joining Student Member $ 25.00

CEU's (awarded by ATRA) $ 10.00

Late Fee (postmarked after 4/8/2000) $ 20.00

Total Fees Enclosed $ ______

Charta's EIN - 52-1690908

Contact Person at Northern Virginia Mental Health Institute - Vanessa Roberts 703-207-7143

For further information about this conference contact,
Michael Duquette, Charta President 301-496-5159, e-mail - mduquette@nih.gov

Make check payable to Charta
Mail completed registration from and check to: CHARTA
C/O Paula Howard, Treasurer
74 Adams Street, N.W.
Washington, D.C. 20001