***PROFESSIONAL GOVERNMENT EDUCATORS, INC.***

2010 SEMINAR REGISTRATION FORM

I wish to register for the_______________________________seminar
(Insert title of seminar)
to be held at (Please check one of the following locations):

______Holiday Inn, Cherry Hill, NJ on________________________________________________________
(week day), (month, date, year)

______Hilton Garden Inn, Rockaway, NJ, on____________________________________________
(week day), (month, date, year)

______Louis Bay II Library, Hawthorne, NJ on______________________________________________________
(week day), (month, date, year)

______Days Hotel - East Brunswick, NJ on___________________________________________________
(week day), (month, date, year)

PLEASE MAIL VOUCHERS AND CHECKS TO:
Professional Government Educators, Inc.
P.O. Box 237,
Cedar Grove, NJ 07009

REGISTRATION FORMS MAY BE FAXED TO (973) 784-4432
_____________________________________          _____________________________________
                                   (Name)                                                  (Title)

___________________________________          ___________________________________
                    (Street Address or PO Box)                     (City, State, Zip Code)

______________________________________          ______________________________________
                    (Municipality or Organization)                     (Telephone No.)

This form has been determined by the Division of Local Government
Services to meet the requirements of the statutes for this type
of expenditure.

CLAIMANT'S CERTIFICATION & DECLARATION

I do solemnly declare and certify under the penalty of law that the within bill is correct in all its particulars, the articles have been furnished or services rendered as stated herein, that no bonus has been given or received by any person or persons within the knowledge of this claimant in connection with the above claim, and that the amount charged is a reasonable one.

Just send your check with the application form! You do not need to send us your voucher for a separate signature since the pre-signed certification at the left can be attached to your voucher in lieu of sending another one for signature. This form has been determined by the Division of Local Government Services to meet the requirements of the statutes for this type of expenditure.

   William M. Homa
   President