HNBA/VIA AC2021 In-Person Gala Request Form

AC2021 Registration First Name:*

AC2021 Registration Last Name:*

AC2021 Registrant E-mail:*

E-mail of Individual Completing This Form (if different from above, to receive copy of form submission):

PLEASE CHOOSE ONE OF THE FOLLOWING REFUND OPTIONS:

- Option A: Pay It Forward - Donate to the HNBA VIA Law Student Scholarship Fund
- Option B: Request a Full AC2021 Gala Fee Refund

Select Option*

Option A: Pay It Forward

Option B: Full Refund

Please complete the subtraction math problem below before clicking submit.