AFFILIATE
REGISTRATION  FORM
DEADLINE: [XXXXXX]
*NO LATE REGISTRATIONS WILL BE ACCEPTED

ACCESSING SAFETY INITIATIVE
[MEETING TITLE]
[MEETING LOCATION]
[MEETING DATES]

	
Please do your best to answer all questions as completely as possible to assist Vera staff in the planning process.
We are looking forward to meeting with you in [XXXXXX]!































































PLEASE RETURN THIS FORM IMMEDIATELY TO: HILARIE ASHTON  
BY FAX AT (212) 941-9407 OR EMAIL AT HASHTON@VERA.ORG