Event Registration Hotel Reservation

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					National Outreach Scholarship Conference                          Four Ways to Register
                                                                  (1) Online:         www.OutreachScholarship.org
Raleigh, North Carolina                                           (2) Fax:            919.515.7614
October 4-6, 2010                                                 (3) Mail:           Office of Professional Development
                                                                                      Campus Box 7401
Registration Form                            (AONOSC10)                               Raleigh NC 27695-7401
Your registration will not be processed until payment is                              Attention: Registration Coordinator
received. Be sure to complete and include page two                (4) Telephone:      919.515.2261
                                                                                      (Monday through Friday from 8:00 a.m. to 5:00 p.m. ET)
when sending this form.



Name – please print or type                  Preferred name for badge               Date of birth (used for internal record keeping)

Business mailing address or check here if home address


City                                                  State                                                    Zip Code


Home phone                                            Work phone                                               Fax
_______________________________________________________________________________________________________________________________________
Position/Title                                        Organization

  Dietary restrictions __________________________________________________________________________________________


EVENT REGISTRATION FEES PRIOR TO AUGUST 1
   Participant full conference registration - $394                       Student/Community Partner/ Collaborator fees:
   One-day rate, Monday Oct. 4 - $100                                       Full conference registration - $354
Includes Monday evening reception                                           One-day rate Monday Oct. 4 - $60
   One-day rate, Tuesday Oct. 5 - $270                                   Includes Monday evening reception
Includes Tuesday breakfast, lunch and evening reception, and                One-day rate Tuesday Oct. 5 - $230
morning and afternoon refreshment breaks.                                Includes Tuesday breakfast, lunch and evening reception, and
   One-day rate, Wednesday Oct. 6 - $150                                 morning and afternoon refreshment breaks.
Includes Wednesday breakfast and lunch and morning                          One-day rate Wednesday Oct. 6 - $110
refreshment break.                                                       Includes Wednesday breakfast and lunch and morning
                                                                         refreshment break.

Pre-conference Workshops -- $50.00 each:                                 Pre-conference Tours
                                                  ssier                    North Carolina Value-Added Seafood and Marketing Tour -
(AOSYEAD10)                                                              $65 (AONCSMT10)
                                                                           Exploring Engaged Universities – Public & Private - $25
Application (AODKREAA10)                                                 (AOEEU10)
                                                                            Urban Engagement – The Durham Experience - $35
                                                                         (AOUE10)
                                                                           Centennial Campus – Business Model for Engagement -
                                                                         $35 (AOBME10)

   One-year subscription to the Journal of Higher Education Outreach and Engagement: $48. This special price reflects a 20%
discount from the usual $60 subscription fee. This one-year subscription will be for four issues of the Journal in calendar year 2011.
(AOJHEOE10)

Are you a first-time participant?           Were you recruited by a past participant?
If yes, please provide the name and telephone number of the person who recruited you:

Name                                                                                                           Telephone number

                                                              Page 1 of 2
                        Note: This page must accompany page one of the registration form.

Method of Payment:
Payment must accompany registration form and be received by the first day of the conference.
Payor:                                        $_________________________________________________
                                              Total fees paid

The easiest way to guarantee your place is to pay with a credit card.
                   check payable to North Carolina State University (mail only).
                   Purchase Order document made payable to North Carolina State University (may be faxed or
mailed).
                 credit card:
                    Card              Visa       American Express
         Is this a corp

_______________________________________________________                     _____/_____
Card number                                                                 Expires

______________________________________________________________________________
Cardholder’s name (please print)

______________________________________________________________________________
Cardholder’s signature (required) (Seal)



  IDT (NC State University employees only):

_____________________________________                             ______________________________________
OUC #                                                             Project (FAS) #




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