The Dayton Urban League, Dayton Ohio



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2007 Nationwide Insurance Ohio Young Black Professionals Conference

2007 OHIO BLACK YOUNG PROFESSIONALS CONFERENCE REGISTRATION FORM

Schedule At-A-Glance Workshops In Detail

Salutation:
First Name:
Last Name:
Title (if applicable):
Address1:
Address2:
City:
State:
Zip Code:
Phone (day):
Phone (eve):
Email:
Fax:

PAYMENT INFORMATION

*Card Type:
*Card Number:
*Name on Card:
*Expiration Date:	*Month	*Year

By Mail: Please complete and print out this page and include your check or money order (make out and send to Dayton Urban League, 907 W. Fifth Street, Dayton, Ohio 45402) – Your registration will not be confirmed until we receive your check.

Conference Registration – Fee includes conference bag, conference badge (required to attend all sessions, social events and luncheon), membership to the Dayton Urban League* and a variety of giveaways from sponsors.

Attendee Type:

(First 100 registrants get $25 discount)

Select Your Workshops – Choose one workshop per session time:

Session 1:

Session 1 (2nd choice):

Session 2:

Session 2 (2nd choice):

Session 3:

Session 3 (2nd choice):

Session 4:

Session 4 (2nd choice):

Tavis Smiley Luncheon Only:

Number of Individual Tickets:

Bus Tour Registration – Complimentary and available only to conference attendees

Number of people:

Purchase order number (if applicable):

Total of order:

Use this field for Any special needs: In case of emergency, please contact:
Name Relationship Phone (Daytime) Phone (Evening):

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