“YESTERDAY, TODAY AND TOMORROW”

2013 WORKERS’ COMPENSATION SYMPOSIUM REGISTRATION FORM

REGISTRATION TYPE

  $225 — Early Registration submitted or postmarked by September 20, 2013

  $275 — Late Registration submitted or postmarked after September 20, 2013

BREAKOUT CHOICES

  Morning Breakouts I — 9:00 a.m. - 10:15 a.m.

  Afternoon Breakouts I — 1:30 p.m. - 2:45 p.m.

         circle one:      1      2      3      4

         circle one:      1      2      3      4

  Morning Breakouts II — 10:30 a.m. - 11:45 a.m.

  Afternoon Breakouts II — 3:15 p.m. - 4:30 p.m.

         circle one:      5      6      7      8

         circle one:      5      6      7      8

LUNCHEON CHOICES

  Italian Herb Chicken:

Marinated breast of chicken with tomatoes, fresh basil, mozzarella cheese in a sherry tomato cream sauce, roasted red potatoes and seasonal vegetables.

  Grilled Hanger Steak:

Hanger steak in a pinot noir reduction, whipped Yukon gold potatoes with gorgonzola butter and seasonal vegetables.

  Vegetarian Selection:

Penne pasta with spinach, tomatoes, artichokes and red roasted peppers in a garlic white wine sauce.

REGISTRANT INFORMATION

NAME ______________________________________________________________________________

BUSINESS __________________________________________________________________________

ADDRESS ___________________________________________________________________________

CITY _______________________________________________________________________________

STATE ___________________________________ ZIP _______________________________________

PHONE ________________________________ EMAIL* ______________________________________
                                                                                *Email address required for registration confirmation.
 

NUMBER OF REGISTRANTS _______ x REGISTRATION FEE $ _____________ = TOTAL $ _____________
 

Please return your payment, payable to Workers’ Compensation Commission, along with this registration form to:

Workers’ Compensation Commission, Office of the Chairman, 21 Oak Street, Hartford, CT 06106