EmailMe Form - 93rd Northern Province Council-Silhouette

Name *

First Last Suffix

Kappa's Name *

First Last

Select Box (if applicable)

Widow

Phone *

### - ### - ####

Email *

Chapter *

Voting Status *

Chapter Officer *

Province Office *

Financial (Y/N) *

Registration Description

Early registration $192.20 ($185.00 +$7.20 processing fee)

Regular registration $207.74 ($200.00 + $7.74 processing fee)

Late/Onsite registration $223.28 ($215.00 + $8.28 processing fee)

Saturday Banquet Only - $104.12 ($100.00 + $4.12 processing fee)

Early Registration (Jan 27 - Feb 21, 2025)
Regular Registration (Feb 22 - Mar 21, 2025)
Late Registration (Mar 22 - April 2, 2025) *

Diamond Achievement Foundation Breakfast Pinning Ceremony *

Would you like to attend the Motown Museum Tour on April 5, 2025? *

Entree Choices

Please indicate your selections

Saturday Banquet *

Payment Structure

***Registration and payment amount MUST be received or postmarked within the specific registration period to receive that registration rate.***

***Upon submitting your registration, you will receive an email confirmation. If mailing your payment, checks should be made payable to the Northern Province and sent to:

Raymond Wiggins
4652 Ottawa Dr.
Lake Orion, MI 48359

Payment Acceptance Agreement *

I have read and accept the payment structure as printed above.

Payment Options *