Family Federation for World Peace and Unification

Original Divine Principle Workshop, June 4 – 8, 2009

Registration Form
Please respond via email: jheller@familyfed.org or by fax: 646-293-1627 
District No.      

Your Full Name below Gender: Male Female Registration Fee: $500.00
                 
First Name Middle Name Family Name
Badge Name — as you would like to see it on your Name Badge

           
Honorific Full Badge Name

Your Organization:      

Your Position:     

Mailing Address:           

Street Name Suite No.
                 
City State Zip Code
                 
Office Telephone Office Fax Cell Phone
           
Home Telephone Email Address

Flight Arrival in Las Vegas, NV

                       
Arrival Airport Arrival Date Arrival Time Arrival Airline and Flight #

Flight Departure From Las Vegas, NV

                       
Departure Airport Departure Date Departure Time Departure Airline and Flight #
Single Room
Roommate requested:       I will pay an additional $50 per night

Emergency:                        

Contact Person Name Cell Phone Home Phone

Guest Signature:       Date:      

Sign if by fax. If submitting by email, type in name.

Invited By:      

Home Tel:       Email: