Leon H. Sullivan Foundation
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Registration Form

Individuals wishing to attend the activities of the Leon H. Sullivan Summit will be charged a registration fee. Charter Summit participants will have access to the plenary sessions, the exhibit hall, the entertainment events, official meal functions, receptions, workshops, and will receive conference registration materials.

Note: Registration is not complete until requests are received and approved.

* = required

First Name:
Last Name:
Passport Number:
(Charter only)
Passport Expiration Date:
(Charter only)
Organization:
Position:
Address:
(No P.O. Boxes)
Address 2:
City:
State:
Zip Code:
Country:
Day Phone:
Evening Phone:
Email:*
Fax:
Gender:
Registration Package Options:

 

Accommodations Desired

(Charter Package Only)

 



Age Range:
Other (Explain):

 

Roommate Request

(Charter Package Only)

Name of roommate choice:

 

Payment

Payment Method*
Amount
(Cash, Check, Draft, Wire)
Credit Card Number:
Expiration Date:
Name on Card:
Address:
Address 2:
Amount to be charged:

*There is a return item fee of $50 for non-sufficient funds.

 

Terms and Conditions

I have read and understand the terms and conditions and the cancellation policy of the Leon H. Sullivan Summit described on the following pages. *

Questions/Comments? [email protected]

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