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People to People Ambassador Programs - registration (Page 1)

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People to People Ambassador Programs - registration
1. NAME OF DELEGATION LEADER: __________________________________________ DEPARTURE DATE: ________________________________
2. DELEGATE INFORMATION
(Circle preferred title and use preferred first name)
Mr., Mrs., Ms., Miss, Dr., Prof. _______________________________________________________________________________________________
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MALE
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FEMALE FIRM / ORGANIZATION NAME: ________________________________________________________________________
OCCUPATIONAL TITLE: _____________________________________ SPECIALIZATION: ______________________________________________
ADDRESS: _____________________________________________________________________________________________________________
___________________________________________________________________________________________
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Business
r
Home
HOME PHONE: ( ) _______________________________________________ E-MAIL: ____________________________________________
BUSINESS PHONE: ( ) ___________________________________________ FAX: ( ) _______________________________________
EMERGENCY CONTACT: ___________________________________________________________________________________________________
After we receive your registration form, we will send you a professional delegate profile form to fill out (this will facilitate professional arrangements).
3. ACCOMPANYING GUEST
(Circle preferred title and use preferred first name; if professional delegate, complete a separate form.)
Mr., Mrs., Ms., Miss, Dr., Prof. _______________________________________________________________________________________________
STREET ADDRESS: _______________________________________________________________________________________________________
OCCUPATION: __________________________________________________________________
PHONE: ( ) ________________________
4. PASSPORT AND VISA INFORMATION
(Passport not necessary for registration, although you should apply for one as soon as possible.)
Delegate: Full legal name as it appears on passport ____________________________________________________________________________
Birthdate ____________________________________________ Birthplace __________________________________________________________
Citizenship ________________________________________________
Passport No. _______________
Exp. Date ______________________
Guest: Full legal name as it appears on passport ______________________________________________________________________________
Birthdate __________________________________________
Birthplace __________________________________________________________
Citizenship ________________________________________________
Passport No. _______________
Exp. Date ______________________
5. ROOMING
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Please assign a roommate
(additional charge if none is available)
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Non-smoker
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Smoker
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Either
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I will room with ______________________________________________________________________________________________________
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I will room alone
(additional charge)
6. DEPOSIT
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Enclosed is my check in the amount of $ ______________ (minimum U.S. $500 per delegate or guest) as a deposit toward membership in this
delegation. I understand this registration is subject to the Information for Delegates on reverse side. (All checks are to be made payable to
People to People Ambassador Programs; mail to Dwight D. Eisenhower Building, S. 110 Ferrall Street, Spokane, Washington, 99202.
Fax number: 509-534-5245.)
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I authorize $ ____________ (minimum U.S. $500 per delegate or guest) deposit to be charged to my credit card. Bill me for the balance.
Signature as shown on card: ________________________________________________
Expiration Date: _______________________________
7. SIGNATURE
I have read and agree to the Information for Delegates on reverse. ________________________________________________________________
(name)
(day phone)
(evening phone)
Card
number:
month / day / year
IMPORTANT: Please print or type; photocopy, fill out, and submit this form for any accompanying guest who will participate as a professional delegate. Provide street addresses
wherever possible to ensure accurate express mail delivery.
(first)
(middle)
(last)
(first)
(middle)
(last)
FOR OFFICIAL USE ONLY
Partic. ______________ Leader _________________ Program ____________________ Letter Code ____________ Spouse Code ___________
Partic. ______________ Leader _________________ Program ____________________ Letter Code ____________ Spouse Code ___________
People to People Ambassador Programs
v
S. 110 Ferrall Street
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Spokane, WA 99202-4800 USA
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509-534-0430
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fax: 509-534-5245
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E-mail: ptpap@ambassadors.com
People to People Ambassador Programs Registration
ptpap-1-99

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