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Forum 2012 Attendee Registration Form

INFORMATION
First Name Last Name Title Organization
Member

Questions? Contact Christine Kim at 1.202.667.8227 or email ckim@interaction.org

Address_ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ _ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ City _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ State _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | Zip _ | _ | _ | _ | _ Phone _______________ Fax _______________ E-mail _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _
Registration confirmation will be sent via E-mail

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As you wish to appear on your name tag at the forum _ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ _ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ _ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_ |_

Nonmember nonprofit Corporate Government

I am in need of special accomodations. If so, please describe:_________

________________________________________________________

MEALS & FUNCTIONS

The following meals are includued in your complete forum registration.

Need extra tickets?

Wednesday, May 2

Monday, April 30

Tuesday, May 1

Networking Luncheon Exhibit/Happy Hour

SPECIAL ACCOMMODATIONS
I prefer vegetarian meals

Plenary Breakfast Plenary Luncheon Gala Reception Gala Dinner

Exhibit Hours Breakfast Closing Plenary Luncheon

GALA PLENARY & AWARDS BANQUET

Full Table (9 Additional seats for $800) Additional Seat Tickets are $100 each. How many? _____ TOTAL $ _____________

I have special dietary needs as follows: ___________________________________________________________________________

REGISTRATION FEES:
Registration fees include admission to all meals and functions offered that day. Minimum registration is one full day. Registration will not be processed until payment is received by check or credit card. Registration confirmation will only be sent after payment has been received. Cancellations must be submitted by email to forum@interaction.org by March 31, 2012. * Group discounts are available for large numbers from a single organization. Please contact Christine Kim at ckim@interaction.org.

CATEGORY
InterAction Member InterAction Member >300 miles Nonmember Participant from Southern Organization Young Professional (<30 years old) Full-time Student or unpaid Intern (must provide copy of student I.D. or appointment letter)

Early-Bird Full-Conference Rate (until Jan 20)

$500 $450 $600 $450 $450 $250

Regular Rate (effective Jan 21)

$600 $550 $725 $475 $475 $250

On-Site Rate (effective April 30)

$675 $625 $750 $475 $475 $250

One-Day Rate
$275 $225 $350 $250 $250 $150

I would also like to donate $________ to the Forum scholarship fund enabling students, young professionals and global south particiapnts to attend.

TOTAL $ _________

(Include cost of additional ticket(s) for Gala if necessary)

PAYMENT INFORMATION

Make checks payable to InterAction

Be sure to write FORUM and the registrants name in the memo field. Send payments to: InterAction, Attn: Forum Registrar 1400 16th Street, NW, Suite 210 Washington, DC 20036 USA Tel: 1.202.667.8227 Fax:1.202.729.6728 Email: forum@interaction.org

VISA Master Card American Express Card Holders Name _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ Credit Card Number _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ Expiration Date ____/____/______ Card Holders Signature ________________________ Date ____/____/______