Registration Form

Name:___________________________________________________

Address:_________________________________________________

City, State, Zip:___________________________________________

Daytime Phone:___________________________________________

Email:___________________________________________________

Institutional Affiliation:______________________________________

If a teacher, do you need clock hours? y n

MOHAI is ADA Accessible. Please call 206-324-1126 for further information.

Saturday conference:   number of registrants:	________________________
Early Registration by Tues. Feb. 17th:	___ at $30 each	= ________
Late Registration:	___ at $35 each	= ________
Saturday Buffet Lunch:	___ at $12 each	= ________
Friday Night Package:    number of registrants:	________________________
EMP Tour & Liquid Lounge Social Hour & Appetizers     Please RSVP by Sat. February 27st!	___ at $32 each	= ________
2004 Membership in PNW Historians Guild	___ at $20	= ________
Total enclosed		= ________
VISA MC card # ___________________________________ exp. date ____________
OR check # __________ enclosed

Send completed form with payment to:
MOHAI - Guild Conference
2700-24^th Avenue East
Seattle, WA 98112

For more information, contact Chuck Richards at csr@pnwhistorians.org.