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-MAIL ADDRESS PRIMARY LOCAL ASSOCIATION Payment CHECK PAYABLE TO VAR CASH CHARGE MASTER CARD/VISA/DISCOVER/AMEX CARD HOLDER S NAME EXPIRATION DATE CARD NUMBER SIGNATURE Signature indicates acceptance of 2011 registration policies and authorization of any Master Card/ Visa/ Discover/AMEX charges. Registration: The deadline to register is November 23, 2011. Venue: Omni Charlottesville Hotel, 235 West Main St, Charlottesville, VA 22902. Reservation information will be sent on.

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