KSRT 2016 Annual Convention

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First Name: *

Last Name: *

Address: *

Phone #: *

Email Address: *

Select the days you wish to attend: *

Please Choose

Select your status: *

Please Choose

Please choose if you are attending the Past President Lunch and or the Friday evening Reception: *

Please Choose if

Past President Lunch

Friday Evening Reception

Required

Check if you wish to bring an item for the silent auction to fund the KSRT Scholarships

Please select if you will be providing an item

Yes I want to provide an item for the silent auction

Payment Type *

Please Choose (If using PayPal please follow link on our home page ksrad.org to make payment)

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