2016 Housing Conference for LeadingAge New York April 12-14, 2016 | Page 9

Housing Professionals Annual Conference Registration Form (page 2 of 2) April 12 – 14, 2016 Name: _____________________________________________ Title: ______________________________________________________ Organization:____________________________________________________________________________________________________ Payment Method: Please select:   Check   MasterCard   Visa   Discover  Amex Credit card number: ________________________________________________________________________________________________ Exp.:_______________________ Security code: ___________________ Cardholder’s name (exactly as on card):________________________________________________________________________________ Authorized signature: _______________________________________________________________________________________________ Payment in full must be received by the date of the conference to ensure your entry. Make check payable to Foundation for Long Term Care Complete registration form and return with payment to: Foundation for Long Term Care Fax: [phone] Phone: [phone], ext. 154 Mail: 13 British American Blvd., Suite 2, Latham, N.Y. 12110-1431 Questions? Contact Michelle Mahoney at [email protected]