Tribute to Dr. Samuel L. Myers, Sr.
MINORITY ACCESS’ TWENTIETH
NATIONAL ROLE MODELS CONFERENCE
~ September 26 - September 29, 2019 ~
REGISTRATION FORM
Gaylord National Resort & Convention Center
201 Waterfront street, National Harbor, MD 20745-1135
Telephone:
(301) 965-4000
FULL NAME
Title
Mr.
Mrs.
Ms.
Dr.
First Name
*
Last Name
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Job Title
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ADDRESS
Institution/Organization
Department
Street Address 1
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State
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Zip Code
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E-Mail Address
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PACKAGE SELECTION
Payment Method
*
Visa
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AMEX
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Check
Purchase Order
Select your package
*
Tribute to Dr. Samuel L. Myers, Sr. - per ticket
$
200.00
Tribute to Dr. Samuel L. Myers, Sr. - per table of 10
$
2,000.00
Select your package
*
Tribute to Dr. Samuel L. Myers, Sr. - $200.00
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