International Social Service - United States of America Branch, Inc.

(This form may be completed on line and paid for with a credit card through PayPal or downloaded and mailed with a check to ISS-USA. ISS-USA does not have the ability to process credit card charges except on-line.)

Registration will remain open until 5:00 p.m. on Monday October 19th, 2009 UNLESS all spaces for the conference are filled prior to that date.

First Name: Middle Initial: Last Name: Title: Agency: Address Street: Appartment/Suite: City: State: Zip: Phone: Email: Special Needs: Yes    No Special Needs detail: Meal Preference: None Vegetarian Vegan Kosher Registration Type: Non-presenter - $195 Presenter - $75 Student (with valid Id) - $75 CEU Fee: Yes ($25.00)   No   Would you like to receive information about hotels near the conference site?  Yes    No For additional information please contact Dr. Felicity S. Northcott at fnorthcott@iss-usa.org or by phone at 443-451-1209.