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
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
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
Centennial Campus – Business Model for Engagement -
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.
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
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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.
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
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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