Maple Certificate Registration
* Denotes Required Field.
NAME
*
PERMANENT STREET ADDRESS
CITY
STATE
ZIP
*
COUNTRY
*
HOME PHONE
CELL PHONE
EMAIL
*
DOB
GENDER
Male
Female
U.S.CITIZEN
Yes
No
ETHNICITY
Non-Resident
White / Caucasian
Black / African America
American Indian / Alaska Native
Hispanic / Latino
Asian
Native Hawaiian / Other Pacific Islander
Other
VETERAN STATUS
Not a U.S. Veteran
U.S. Veteran
U.S.Disabled Veteran
Active Reserve
Inactive Reserve
I WANT TO SIGN UP FOR:
*
Select
$200 - Registration Fee & Certificate
$300 - Registration Fee, Certificate & Accommodations
Declaration
*
I agree that by Checking this box and submitting this form that all information is accurate to the best of my knowledge.
Submit
