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2015 form nm autosaved rclubrunner.blob.core.windows.net/.../2015-form-nm-_autosaved_r.pdf · 2015...

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  • 2015 Form NM Autosaved rclubrunner.blob.core.windows.net/.../2015-Form-NM-_Autosaved_r.pdf · 2015 Form NM _Autosaved_r Author: Steven Sanfilippo Created Date: 3/16/2015 3:44:27 PM
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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 1 st 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

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Page 1: 2015 Form NM Autosaved rclubrunner.blob.core.windows.net/.../2015-Form-NM-_Autosaved_r.pdf · 2015 Form NM _Autosaved_r Author: Steven Sanfilippo Created Date: 3/16/2015 3:44:27 PM

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

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