National Hispanio/Latino Community Prevention Network

El Puente to the New Millennium IV Conference

"El Puente: Pasos Adelante/Stepping Forward"

REGISTRATION FORM

To register please print this form and fax to (505)747-1623

Attention Valerie Vigil

Valerie  can also be reached at (505)747-1889 or by email

HACC@cybermesa.com

                             Or write to: Hands Across Cultures, Inc. P.O. Box 2215 Espanola, NM 87532

National Hispano/Latino Community Prevention Network

El Puente to the New Millennium IV Conference

"E l Puente: Pasos  Adelante/Stepping Forward"

October 23 & 24, 2003

Name: ____________________________________________________________________________________

Title: _____________________________________________________________________________________

Name as it will appear on name badge: __________________________________________________________

Company Name: ___________________________________________________________________________

Address: __________________________________________________________________________________

City: _________________________              State: ________________              Zip: _____________________

Telephone: ____________________               Fax: ________________________________________________

email Address: _____________________________________________________________________________

If you have any special needs due to physical conditions, please advise as to the conditions 

and what will be required to assist you: __________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Registration Rates

Pre-registration rates are available until October 10, 2003. All registration forms received after this date will 

be processed at a flat $200 fee. Students must provide copy of current validated student identification or 

enrollment record.

Full Registration

                             By 8/22/03                  By 10/10/03           Quantity                      Total                

Individual*         $150                     $175                ______               $______

Student               $80                                               ______               $______

On-site registration $200 after 10/10/03 

* On site registration $200. Fax or Mail by October 10, 2003. After October 10, you must 

register on-site.

Method of Payment

Please fax registration form to (505) 747-1623. If unable to fax registration form, please mail 

to the address below.

To avoid duplicate registrations, please DO NOT fax form if you are submitting it by mail.

Total Amount Due: (Add all numbers in TOTAL column above)   $_______________

Check or Money Order (make payable to Hands Across Cultures)

Purchase Order (enclose copy of your purchase order)

Terms: To qualify for discount, form must be postmarked on or before October 10, 2003, or received by fax 

prior to 5:00 PM MST on October 10, 2003. Full payment must accompany registration form. Cancellations made

before 5:00 MST on October 10, 2003,  will be charged 15% of the registration fee. Cancellations after that date 

will be 50%. No refunds will be given for cancellations received after 5:00 PM MST October 13, 2003. All 

cancellations must be made in writing. This contract will not be binding upon the NHLCPN in the event 

of any state, lockout, injunction, act of war, act of God, emergency declared by any government agency or any 

other circumstances beyond the control of the NHLCPN is not replacing lost or stolen tickets.

National Hispano/Latino Prevention Network

c/o Hands Across Cultures, Inc.

P.O. Box 2215

Espanola, New Mexico 87532

(505) 747-1889 Telephone

(505) 747-1623 Fax