Registration Form

Conference Registration Form

Name:

Address:

City / State / Zip Code:

Organizational Affiliation:

Phone (Home):

Phone (Work):

Phone (Fax):

E-Mail Address:

For the Saturday Group Sessions (click here), I am attending the following:

1st Choice:

2nd Choice:

3rd Choice:

I request Japanese simultaneous translation for general sessions.

I would prefer small group sessions conducted in Japanese.

My organization is interested in an Information Table; please send a form.

My organization wants to participate in the Community Directory; please send a form.

Conference Fees:

___ $45 General Registration $__________

___ $20 Student and Limited Income $__________

___ $20 Dinner: Empress Pavillion $__________

Total
$__________

Enclosed is my check

Make check payable to "Little Tokyo Service Center", and send to:
Little Tokyo Service Center
231 East Third Street, G-104
Los Angeles, CA 90013

Check Memo: "Ties That Bind"

Please charge my: MasterCard Visa

(Note: $2 credit card handling charge per registration.)

MC/Visa # ______________________________

Exp. Date ______________________________

Signature ______________________________

Please print out and mail this form to:

"Ties That Bind" Conference
c/o Bill Watanabe
Little Tokyo Service Center
231 East 3rd St, Suite G-104
Los Angeles, CA 90013