12th ABLA CONVENTION 2012Santo Domingo, DN; Dominican Republic

Leaders Convention Librarians Convention ELT Convention

International Registration Form

First Name: dfgdfg Last Name: sdfgsdfg

Institution: Centro Cultural Colombo Americano, Cali

Position: sdfgsdfg Country: Chile

City: sdfg

Postal Code: sdfgsdfg Mailing address: asdgsfg

Telephone: sdfgsdfg Fax: sdfgsdfgsdfg

E-mail: pablovv2008@hotmail.es Date: Fri, 29 Jun 2012

How your name will appear on the certificate? sdfgsdfg

Payment information:

Three-day Librarians' Convention (November 12th - 14th, 2012)

Total:

US $225.00

Payment method:

VISA MASTER CARD AMERICAN EXPRESS

Credit Card Number: Cardholder's name:

Expiration date: Security code:(Last three digits on back of card)

* Early Registration: If you register before June 30th, 2012, you will receive a US$20.00 discount.

* Regular Registration: Registrations submitted between July 1st and September 30th, 2012.

* Late Registration: If your register after October 1st, you will be charged an additional fee of US $25.00.

+ Additional 20% discount if three or more people from the same BNC register before June 30th, 2012.

City: Signature: Date:

Fill up this form and send it to this Fax number 8092552600

Av. Abraham Lincoln #21, Santo Domingo, República Dominicana,Tel. 809-535-0665, ext. 2202, 2102