ABCC Registration Form by mallorycarlson


                             Association for Black Culture Centers
                                   19th National Conference
                                    November 5 – 8, 2009

                                                Registration Form

                               Co-Sponsored By:         The Cleveland State University
                                                            Black Studies Program
                                                              (216) 687-3655

Registrant Information (please print or type)
ZIP Code
Telephone/Cell No.
Telephone (business)

Conference Fees
Registration Deadline:         October 4, 2009
Early Registration – (General Non-Member):                                       $ 200.00
Late Registration – (General Non-Member):                                        $ 250.00
Early Registration – (Institutional Member*):                                    $ 150.00
Late Registration – (Institutional Member*):                                     $ 200.00
Early Registration – (College Student):                                          $ 125.00
Late Registration – (College Student):                                           $ 150.00
One Day Attendance – (Does not include meals):                                   $ 100.00
Single Event Registration – (Does not include meals):                            $   35.00
 Optional: Treasurers of Jazz Concert Series Performance                         $ 30.00
(Performer-Vanessa Rubin and Jazz Heritage Orchestra
                                                              Total Amount Sent:_______
Payment Information
Refund Deadline: October 16, 2009
Refund Penalty – 50% refund if cancelled after: October 25, 2009

Preferred Method of Payment: Check ______ Credit Card _____ (Complete form below). Cash payments
are only acceptable at the registration table at late registration fee rates. Pre-registration not required for
cash payments.

If you should have special needs such as mobility or dietary, please contact host site

Credit Card Number
Card Expiration Date
Phone No. (Home) (Work) or (Cell)
Credit Card Type
Amount To Be Paid
Date of Charge
Name As Shown On Card
Authorization Code (3-digit)
Cardholder Mailing Address
Student Name (If Applicable)
Campus I.D. Number If Applicable)
Authorized Signature

Hotel Rates
Hotel Reservation Deadline: October 4, 2009
Single Occupancy (King – Per night)                                                                  $   99.00
Double Occupancy (2 Queen Beds – Per night)                                                          $ 109.00
Hotel Address: Hilton Garden Inn – 1100 Carnegie Ave., Cleveland, Ohio 44115 – (216) 658-6400
Attendees are responsible for making individual hotel reservations.

                                        Please make checks payable to:

                                         Cleveland State University
                                           Black Studies Program

                   Please return this form and direct any registration questions to:

                                           Oretha Barnett
                               Coordinator of Administrative Services
                                     Cleveland State University
                                       Black Studies Program
                                      2121 Euclid Ave, MC 137
                                       Cleveland, Ohio 44115
                        Phone: (216) 687-3655/Email:
•   Registration fees cover attendance at all sessions, conference-sponsored meals, registration packets
    and entertainment except Jazz Concert. Adult One Day Registration and Single Event Registration do
    not include meals or Jazz Concert.
•   Registration forms must be postmarked by October 4, 2009.
•   After October 4, 2009, participants must register at the late registration rate.
*   Attendees whose institution is a paid member of the Association for Black Culture Centers (ABCC).

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