Summit 2004 Registration Form

If you are paying by credit card or your college/university is paying for your registration and you have a purchase order number, please complete the online registration form. ALL FIELDS ARE REQUIRED. If you are paying by check or money order, click here to print out and mail registration form(s) with payment to: NLLC, 28 Allegheny Avenue, Suite 503, Baltimore, MD 21204.

1. Permanent Contact Information

First Name, Middle Initial	.
Last Name
Email
Group or Organization Name
School Name
Permanent Address	Apt.
City, State, Zip	,
Country
Home Phone
2. Campus Contact Information [COLLEGE STUDENTS ONLY]

Campus Address	Box/Apt#
City, State, Zip	,
Campus Phone
3. Local Contact Information
Which hotel will you be staying in? Renaissance Washington DC Sheraton Four Points Other Arrival Date (Check-in): Departure Date (Check-out):
4. Registration and Payment
Registration Level Full Registration [$60.00] One Day Registration: November 19 Only [$30.00] One Day Registration: November 20 Only [$30.00] Payment Options Credit Card My School is Paying--Purchase Order Number

Registration Deadline: October 31, 2004