Technology Workshop Award Application Form
The Technology Workshop Award is for registration to the Technology Workshop (held September 28, 2019) only.

Applicant must be a member in good standing for at least two years prior to applying for a DKG California Award. A copy of the applicant’s registration and proof of payment (a copy or image of your check) for the Technology Workshop must accompany this application. Application must be submitted by October 20, 2019. Reimbursement will be made to the applicant only after successful completion of the Technology Workshop and notification of the Scholarship Committee Chairman.

Email address *
Deadline October 20, 2019
Personal Information
Name: *
Your answer
Date: *
Address: *
Your answer
City: *
Your answer
Zip: *
Your answer
Primary Phone with area code (000-000-000) *
Your answer
List Conventions/Conferences/Study Sessions you have attended in the past two years. (Level: Area/State/Regional/International): *
Type NA if not applicable
Your answer
I grant my permission to be photographed, filmed, videotaped or audio-taped and grant full use of my likeness, name, voice, and words without compensation for use by DKG California. I understand that the above uses may include but are not limited to video, photographs, websites, multimedia programs or other types of promotional medium existing now or in the future, unless revoked. *
A copy of your responses will be emailed to the address you provided.
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