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