SOMOS 25TH ANNUAL SPRING CONFERENCE

SHELDON SILVER
SPEAKER
NEW YORK STATE ASSEMBLY

FELIX W. ORTIZ
Friday, March 23rdSunday, March 25th, 2012
CHAIRMAN
NYS ASSEMBLY PUERTO RICAN/
Albany, New York
HISPANIC TASK FORCE

Conference Registration Form

Participant Name:_____________________________________________

Please check the desired option(s):

Company/Organization:________________________________________

REGISTRATION FEE *

Address:_____________________________________________________

$200.00 ________ $_________

GALA DINNER TICKETS $250.00 ________ $_________

City:______________________ State:____________ Zip:_____________

Phone: _________________________ Fax:_________________________

Total $_________
I am unable to attend, but would like to contribute: $__________

Email:_______________________________________________________

* Registration is required for admittance to all conference activities,

including breakfast sessions, receptions and legislative forums.
Please note that some events require the purchase of tickets. Badges,
Phone: _________________________ Fax:_________________________ conference programs, and conference materials will be distributed at
the onsite registration desk at the Concourse in Empire State Plaza.
Contact Person: ______________________________________________

Email:_______________________________________________________

Method of Payment - Fees Are Not Refundable

Amount:______________ Check #:__________________________ Money Order:_______________________ Voucher:____________________
Credit Card Type:

Amex

MC

Visa #_________________________________ Exp. Date: ______________ Sec.

Code:___________

I authorize the above charges to my Credit Card:

Name of cardholder:__________________________________________
Billing address:______________________________________________

Dinner Gala / Attendees Information

____________________________________________________
Signature

Payment Instructions

Number of Tickets: ____________ @$250.00 Each / Total:$________

Name of Tickets Holders: (If Applicable)

PLEASE RETURN THIS FORM WITH PAYMENT TO:

1. ___________________________ 6. ___________________________

Somos Inc.

2. ___________________________ 7. ___________________________

PO BOX 378
Warwick, NY 10990

3. ___________________________ 8. ___________________________
4. ___________________________ 9. ___________________________
5. ___________________________ 10. __________________________

For more information, please contact:

Stephanie Rodriguez
Tel/Fax: 518-380-6003
Email: somosconference@gmail.com

All 2012 Conference sponsorship levels support the Somos Scholarship Fund
FOR OFFICE USE ONLY. PLEASE DO NOT WRITE IN THIS SPACE.
DATE RECEIVED:___________ CHECK DATE:___________ CHECK NUMBER:___________ CHECK AMOUNT___________
All registrants will be added to the Somos el Futuro mailing list for informational purposes only. Registration forms must be received no
later than March 7, 2012. Any registration received after this date will be processed on-site. Somos el Futuro staff, volunteers, and
sponsors claim no liability for the actions of suppliers to this conference nor the safety of any attendee during or while in transit to or from
this conference.