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~' ~ 2010 HUMAN RIGHTS DAY CONFERENCE REGISTRATION FORM <br />Complete this form and mail with your payment to: Minnesota Department of Human Rights, <br />~ Attn. 2010 Conference, 190E 5th Street, Suite 700, Saint Paul, MN 55101. Our fax number is <br />651.296.9042. You may also register online at: www.humanrights.state.mn.us. <br />Please print clearly. This information will be used to create conference name badges. <br />(®NAME(S) & CONTACT INFORMATION ~ I AM ATTENDING AS A LEAGUE MEMBER ^ <br />NAME/MAIN CONTACT <br />ORGANIZATION <br />ADDRESS <br />CITY <br />PHONE EMAIL <br />ADDITIONAL NAMES (attach another sheet if necessary): <br />I ®AMOUNT DUE -ENTER TOTAL AMOUNT ON BLANK LINE (NO DISCOUNTS FOR HALF DAY) <br />EARLY BIRD RATE: $175/person (must register by Oct. 1, 2010) <br />'! STANDARD RATE: $200/person (registrations after Oct. 1, 2010) <br />LEAGUE RATE (write N/A on line and skip payment method section below) <br />GROUP RATE: ($175/person if registering eight or more people at same time; includes <br />table reserved in group name). Group/organization name: <br />~ ®PAYMENT METHOD -SELECT AND FILL IN 1, 2, OR 3 <br />Registration fees <br />^ 1. CHECK can be refunded <br /> Enclosed amount ~regtstratton is <br /> <br />(Make checks payable to Minnesota Department of Human Rights) cancelled before <br />11120//10; <br />^ 2. ELECTRONIC TRANSFER no refunds. <br /> Transfer # ~~~~• <br /> State Employees paying electronically, use the following information: GFS use Fund 200; Agency <br /> Code G17; Org # 2740; Appropriations SEM; Revenue Source Code 8700, or AGPS Vendor # <br /> 200035981-00. Please list all attendees names on this form. <br />^ 3. PURCHASE ORDER <br /> PO/MAPS # <br />~ VEGETARIAN MEAL ^ YES ^ NO <br />If registering a group, number of vegetarian meals (if any) for your group: <br />STATE ZIP <br />Conference to be held on Friday, Dec. 3, 2010 at the Crowne Plaza Saint Paul Riverfront Hotel, 11 East <br />Kellogg Blvd, Saint Paul, MN 55101. For questions call 651.296.5663/TTY 651.296.1283; Toll Free <br />800.657.3704; or visit us online at: wwwhumanrights.state.mn.us. <br />