Please print this form, fill out the necessary info,
enclose check or money order made payable to BGDDHA, and send to:

BGDDHA Registration
PO Box 23971
Lexington, KY 40523-3971

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Full Name: ______________________________________________________

License #: _________________________________________________

Address: ___________________________________________________

City, State, Zip: __________________________________________

Email: __________________________________________________


Date of CE dinner meeting you wish to attend: _________________________________


Please circle one below:

Students- enclose $20.00 for registration

Member- enclose $23.00 for registration

Potential member- enclose $46.00 for registration


__________ check here if Vegetarian dinner preferred