2006 Pre-Registration Form

NCLR ANNUAL CONFERENCE On-site Pre-Registration Form 2006 ★ Sponsors and Exhibitors DO NOT use this form ★

1.

Badge Information: This is how your badge will read. Please print clearly!

Mr.

Mrs.

Ms.

Dr.

Hon.

First Name

MI

Last Name

Title Company/Organization City

2.

State

Registration Information:

Home or

Country

Business Address

Mailing Address

Suite/Apt.

City

State

Area Code

Phone

Fax

Emergency #

3.

Zip

Email

Participant Profile

To help us serve you better, please provide the following information. All responses are strictly confidential.

Race/Ethnicity Highest Level of Education (check one)

Age A-HS

B-Undergrad

Household Income (to nearest $5,000) $

C-Graduate/Prof

D-Post-Grad

Length of Involvement with NCLR (in years)

While in Philadelphia I will stay at (hotel name or other accommodations)

Please indicate your affiliation (check all that apply)

4.

A-NCLR Board of Directors

B-NCLR Corporate Board of Advisors

C-NCLR Affiliate

D-Individual Associate

E-Foundation

F-Non-govt./Nonprofit Organization

G-Public/Government Agency

H-College or University

I-Hispanic Community-Based Organization

J-Corporation

K-Other

Pre-Registration Fee

Registration fee includes all events listed in the program agenda including meal events, receptions, dances, workshops, plenary sessions, and daily admission to LatinoExpo USA. Please note that due to the popularity of many events, service is extended to guests on a first-come first-served basis. Service and seating cannot be guaranteed at all events. Discounted registration catagories are subject to verification.

2006 Special Rates for 2005 Attendees

Regular Registration

$375.00

Senior *

$150.00

NCLR Affiliate Member**

$200.00

Individual Associate

$300.00

Register and sign up as an NCLR Individual Associate

$450.00

Líderes Summit (ages 14-25)***

$250.00

✦ ✦

*

F1-Send

10 paid registrations TOGETHER in one envelope and receive ONE additional registration FREE for a total of 11 registrations!

F2-Send 15 paid registrations TOGETHER in one envelope and receive TWO additional registrations FREE for a total of 17 registrations!

Proof of DOB required for Senior Discount, must be 65 or older.

** ***

To qualify for the Affiliate rate, registrant must be a member of the staff or board of an organization that has been granted official recognition as an NCLR affiliate prior to May 2006.

The Líderes Summit is an NCLR youth program (ages 14-25). Visit http://lideres.nclr.org/ for details.

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www.nclr.org/conference NCLR Federal ID#86-021-2873

NAME NCLR Special Events — check all events you plan on attending. Registration required.

Saturday Sunday Monday E1-National

Affiliate Luncheon

E4-Latinas

Brunch

E2-Opening

Plenary

E5-Evening

E3-Welcome

Dance

Event ($10.00 Concert Surcharge)

Tuesday

E6-Luncheon

E8-Luncheon

E7-Evening

E9-Awards

Event

Gala

E10-Awards

Dance

5. Method of Payment: Full payment is due and must accompany this signed registration form. Make check or institutional purchase order payable to National Council of La Raza, turn in with this form to the 2006 Conference booth or mail to: NCLR Conference Registation Office c/o Registration Systems Inc., P.O. Box 447 Livingston Manor, NY 12758. Must be Postmarked by August 19, 2005.

Check Number

Purchase Order Number (Original P. O. must accompany this form)

Please charge my (check one):

Visa

MasterCard

American Express

Account No.

Exp.

Print Name on Card Cardholder Signature (required) Cancellation/Refund Policy Cancellations will be accepted IN WRITING until June 9, 2006 and are subject to a $95.00 processing fee. After June 9, registrations are nonrefundable. However, a person from the same organization may substitute or be postponed for the following 2007 conference if notification is received IN WRITING by June 30, 2006; substitutions after this date or on-site will NOT be allowed. A registrant who does not attend the Conference or does not notify NCLR in writing by June 9, 2006 is not eligible for any refund. All refunds will be issued by August 4, 2006.

Liability NCLR and its staff, board, and sponsors claim no liability for the acts of any suppliers to this Conference or for the safety of any attendee during and/or while in transit to or from this event. The planners and sponsors reserve the right to cancel this function without liability. NCLR reserves the right of admittance and the right to exclude from the Conference or refuse service to any attendee at the sole discretion of NCLR. Furthermore, NCLR is under no obligation to provide an explanation for its actions, but may do so at its own discretion.

Photographs As an Annual Conference attendee, I hereby grant to NCLR the right and permission to use, publish, and republish photographs, video, or audio of me or images in which I may be included, in whole, part, or composite in any printed or electronic matter or media for any legal purpose; and to use my name in conjunction if NCLR so chooses. This authorization and release shall also be binding upon my heirs, next of kin, and personal representatives. I have read this release and fully understand its contents.

I hereby release and discharge NCLR from any and all claims and liabilities arising out of or in connection with the use of photographs, images, or information.

Registration Information NCLR uses your demographic information from registrants for marketing related to NCLR programs, activities, and events.

NCLR may also share your contact information with approved NCLR partners. Payment information is not shared and is kept strictly confidential. If you do not wish to have your information shared with NCLR-approved partners, send an email request to Registration Systems, Inc. at attendee@regisys.com stating that you prefer not to have your information shared with NCLR partners.

Authorized Signature

(Registration will not be accepted without signature.)

Printed Name

Date

FAX YOUR REGISTRATION If paying by credit card, you can fax a completed registration form to: NCLR Conference Registration Office Fax: (845) 439-3898 (24-hour line) If you are faxing this form, DO NOT mail the original.

MAIL YOUR REGISTRATION If paying by check, purchase order, or money order, please mail completed registration form and payment to: (Requests must reach our office by 5:00 p.m. E.S.T. on August 19, 2005) NCLR Conference Registration Office c/o Registration Systems Inc. P. O. Box 447 Livingston Manor, NY 12758 Telephone: (845) 439-3893

Americans with Disabilities Act Compliance NCLR will make every reasonable effort to accommodate the special needs of all Conference participants. Please attach a separate sheet indicating any special assistance you require by July 1, 2006 (e.g. wheelchair accessibility, sign language interpreters).

NCLR Federal ID#86-021-2873

www.nclr.org/conference www.nclr.org