Address: _______________________________________________________________

Phone: ________________ Fax:  ___________  NCRA Registration No. ______________ 

Email:  __________________________            Website: __________________________

____ Please contact me about being a GWSRA board member!

                Registration (received prior to Sept 20, 2010)                                $175.00
                Onsite Registration                                                                      $200.00
                Supporting Member (Scopist/Teacher)                                          $75.00
                Senior Member (Over 65)                                                            $50.00
                Student Member                                                                          $50.00

  Price includes one-year membership to GWSRA as well as full convention.

                                                             Please circle appropriate information:          

         Reporter type:            Freelance          Employee          Official (Federal/State)          CART

         Realtime Provider:    Yes         No

         CAT System:           Eclipse      CaseCatalyst       Other: _________________________

         Please provide authorization to release your contact information to advertisers and attendees of the convention.  This information will only be available to those involved with  this year's convention.

_____  I authorize GWSRA to release all of the contact information provided above;

_____  I authorize GWSRA to release the contact information provided above EXCEPT:
        (Circle all that apply)    NAME     ADDRESS     PHONE     EMAIL