Please return this

registration form with

payment to:

Kaua'i Chamber of Commerce

P.O. Box 1969

Lihu'e, HI 96766

Fax to:

245-8815

Online:

www.kauaichamber.org

More info call:

245-7363

No Refunds or

Cancellations after

October 18, 2017

No Shows will be charged

Name: ___________________________ Organization: _____________________

Name: ___________________________ Organization: _____________________

Reservations: ________ x $ 15 = ________ Chamber/KCFB Members

________ x $ 25 = ________ Non members

(includes pupu, refreshment, and movie ticket)

Please provide the names of your guests on a separate paper, or email Anna at anna@kauaichamber.org

Circle Method of Payment: □ MasterCard □ Visa □ Check □ Cash

Credit Card Number: _________________________________________ Exp: _____ / ______

Name of Card Holder: _________________________________________________________

If you need an auxiliary aid in order to participate (ASL Interpreter, captioning, materials in an alternate format, other

assistance) please call Carol at 245-7363 or email info@kauaichamber.org at least five working days before the event.

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