First Name:	Middle Initial:
Last Name:
Prefix/Title:	Dr. Mr. Ms.
District:
Position:
School:
Address:
City:
Zip:
Office Phone:
Office Fax:
E-mail:	* Required
Home Address:
Home City:
Home Zip:
Home Phone:
Mobile Phone:
Previous Cadre:
Which cadre would you like to be in this year?

2011-12 Options:

Full KLA (Cadres and National Events) $600

Cadre Only $325

National Consultant Events Only $325

Payment Options:

Check (Note: I have printed this form and mailed with my check to 154 Consumer Lane, Frankfort, KY 40601)

Purchase Order #

Invoice District after July 1, 2011

**Invoicing Notes:

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Wayne Young, Executive Director, General Counsel
Rhonda Caldwell, Deputy Director
Clyde Caudill, Legislative Liaison
Wanda Darland, Web, Publications, & Affiliate Services Coordinator
Shirley LaFavers, Director of Professional Development

152 Consumer Lane
Frankfort, KY 40601
(800) 928-KASA or
(502) 875-3411

Fax (502) 875-4634