Distinguished Diversity Dialogue Event
Emory University, Tull Auditorium
American Institute for Managing Diversity, Inc
December 8, 2010, 6 – 9 pm
REMIT PAYMENT AND FORM TO: AMERICAN INSTITUTE FOR MANAGING DIVERSITY, INC.
Attention - Delana Kiett, 1200 West Peachtree St., N.W., Suite 3, Atlanta, GA 30309 or
Fax completed form to 404-575-2139
(Confirmation Notice Will Be Sent Upon Receipt of Paid Registration)
Name:Organization:
Title:
Address:
City: State: Zip:
Phone: Email:
Please register me/my organization for the following event
þ as many that apply
(If registering multiple individuals, please complete the ATTENDEE forms accordingly)
General Admission
Diversity Dialogue / $ 25.00/pp x ______
Total:
Pre Event Private Reception
(Includes access to Shirley Sherrod and Dr. R. Roosevelt Thomas Jr. and the book signing) / $250.00/pp x ______
Total:
Student Admission
Includes Diversity Dialogue only / $15.00/pp x ______
Total:
REGISTRATION TOTAL
[Please refer to the “Method of Payment Form”] / $
METHOD OF PAYMENT FORM
CREDIT CARD AUTHORIZATION
Today’s Date
Authorized Credit Card User
Credit Card Billing Address
TOTAL Charge Amount (must specify): / $ ______.______(USD)
Credit Card Type / o VISA
o MasterCard
o American Express
o Discover
Credit Card Number
(please write legibly)
Expiration Date / Month ______/ Year ______
Security Code (3-digit code)
Authorized Credit Card Holder Signature
Card Holder Authorization: I, the above-named authorized credit card user, give American Institute for Managing Diversity (AIMD) and its representative express authorization to charge my credit card for the purposes detailed above. I understand that this form constitutes a legally binding contract and that by affixing my signature to this form, I will be held responsible for all agreed upon (as stated above) charges as well as any and all collection and legal fees. This credit card is authorized for only the charges notes above and I understand that I must submit a signed ‘Credit Card Authorization’ form should I desire to charge additional fees not covered on this document. By signing this “Credit Card Authorization” form, I/my organization acknowledge receipt and understanding of its contents, including this “Explicit Authorization” clause.
OTHER PAYMENT METHOD(S):
Check for $______is enclosed. Checks should be made payable to:
The American Institute for Managing Diversity, Inc.
1200 West Peachtree St., N.W., Suite 3
Atlanta, GA 30309
Invoice my organization at the address provided on the Sponsor Commitment
Form. Please note that a purchase order number is required to generate an invoice.
PO#:______
AIMD is a nonprofit 501(c)(3) public interest organization
EIN: 58-1600953
Please return Registration Form, Method of Payment Form, and Attendee Form(s)
via Fax to (404) 575- 2139 or Mail forms and check to:
Attention: Delana Kiett, American Institute for Managing Diversity, Inc.
1200 West Peachtree, St., N.W., Suite 3, Atlanta, GA 30309
PLEASE RETURN COMPLETE FORMS TO DELANA KIETT via fax 404-575-2139 or email