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Rotarian Information – Please Print or Type Club Name: ___________________________________ Rotarian Name: ________________________________ Badge name/Nickname: __________________________ Address: _____________________________________ City: _________________________________________ State: _________________ Zip: _________________ Preferred Phone: _______________________________ Secondary Phone:______________________________ E-Mail Address: ________________________________
Partner/Guest Information (& Indicate if Rotarian)
� Partner � Guest � Rotarian
Name: ________________________________________ Badge Name/Nickname:__________________________ Children’s Name(s): _____________________________
Check All That Apply as of July 1, 2014
YOU PARTNER/GUEST
� Club President � Club President � President Elect � President Elect � Vice President � Vice President � Secretary � Secretary � Treasurer � Treasurer � Past President � Past President � Assistant Governor � Assistant Governor � Past District Governor � Past District Governor � Paul Harris Fellow � Paul Harris Fellow � Paul Harris Society � Paul Harris Society � Benefactor � Benefactor � Major Donor � Major Donor � District Staff � District Staff � Club Committee Chair � Club Committee Chair � First Time Attendee � First Time Attendee � Other � Other
______________________________________________ Cancellation Policy : $50 per person. Within 7 days prior to arrival is 1st
nights package costs. Alternative individuals may be substituted
Package Rate Includes: Conference registration; Lodging May 1 & 2; Friday night Reception; Friday night dinner party; Saturday breakfast; Saturday evening Governor’s reception with 1 hour open bar and hors d’oeuvres; Sunday breakfast; Coffee breaks; Hospitality Quarters 2 Occupants $895 $__________ Single Occupant $625 $__________ Thursday/Sunday per night $149 (Room Only) $__________ Children in Room (under 18 - no charge) # __________ Food for children (2 Dinners/2 Breakfasts) $ __________ (Under 10/$75; Between 11-18 $150) Total Conference Costs $__________ $200 Deposit by January 15, 2015 $ __________ Balance(s) by March 15, 2015 Number of occupants in room: __________
Special Needs
� Dietary Needs � Physically Challenged
Other Options (Check if interested – Information to follow)
� Hospitality Quarters � Golf Tournament
Payment Options
Check #: ________ Amount Enclosed: $___________ or Credit Card #:________________________________ Expiration Date: ____________ CSC #____________ Signature of Cardholder________________________
Make Checks Payable to : ROTARY DISTRICT 7500 CONFERENCE 2015
Mail Registration to:
District 7500 Conference P. O. Box 8444
Red Bank, NJ 07701
For additional information visit : www.rotarydistrict7500.org
or contact Bill Donnelly @ 732-979-4459 or Jay Patock @732-747-1078