North Little Rock AR, North Little Rock Hotels, Restaurants in North Little Rock

June 27-30, 2012

Register for the 12th International Conference on the Short Story in English

Please fill out the required information below.

Salutation
First Name
Last Name

Address 1
Address 2
City
Country
State
Province
Postal Code

Employer/ University/ Other
Department Name
Position/Title
Address 1
Address 2
City
Country
State
Province
Postal Code

Home Telephone
Business Telephone
Fax
Email Address

Same as Home AddressSame as Business AddressDifferent Address


Address 1
Address 2
City
Country
State
Province
Postal Code

I consent to having my name and email information included in the Conference Delegate List that will be distributed to all conference attendees
I consent to having my name and business contact information released to exhibitors and/or sponsors of the conference

I have the following needs related to my ability to participate in the conference: (Please limit your response to 100 words or less)

Dietary Needs
Other (eg. ASL interpretation, mobility needs, etc.)

Note: Registration fee includes all panels, readings, speeches, handouts, coffee breaks, receptions and cultural events

Conference Participant Fee $250 until midnight Jan 31st, 2012; $275 until midnight April 30th, 2012; $300 from May 1st, 2012 onwards
Student (enclose copy of current student ID)Fee $150 until midnight Jan 31st, 2012; $175 until midnight April 30th, 2012; $200 from May 1st, 2012 onwards

Note: $150 per person until midnight Jan 31st, 2012; $175 until midnight April 30th, 2012; $200 from May 1st, 2012 onwards

Number of Accompanying Persons

Conference Fee	$ 275
Accompanying Person(s)	$ 0
Workshops	$ 0
Coupon	$ -
Total (U.S. Currency)	$ 275

Note: Your credit card statement will read "Down town Riverside RV PK" to show conference charge.

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June 27-30, 2012

Register for the 12th International Conference on the Short Story in English