Event Reservation

When you reserve a seat for an event, you can pay by check or by credit card.

To pay by check, please download, complete and mail in the paper form and check by clicking on the link below.

To pay by credit card, complete the form on this page and pay online.

Event Date*
MM slash DD slash YYYY
Name*
First Name Last Name
Firm
Phone
Fax
Email*
CIPLA Membership Dues paid?*
- Yes
- No
- Student
Please reserve the following number of spaces for me at this CIPLA event.*
Additional Attendees
Please specify the name and membership status of each additional individual who will be attending this event.
Choice of Entrees
Please indicate the quantity for each entree requested.
Vegetarian entree is lacto-ovo unless requested otherwise.
Beef
Beef
Chicken
Chicken
Fish
Fish
Vegetarian
Vegetarian
Number of Attendees
Please indicate below the number of attendees in each membership category.
Member Registration Quantity
Price: $55.00
Non-Member Registration Quantity
Price: $75.00
Student Registration Quantity
Price: $30.00
Total
$0.00
Credit Card
Please enter your credit card details. Note that the expiration date and CVC code are required - enter them to the right of the card number.
Card Details
Cardholder Name
Name
This field is for validation purposes and should be left unchanged.