Preferred Name

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Organization

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To pay by Credit Card please complete the information below and submit via email or fax. If you are paying by check, please make check payable to Penn State University and mail with a copy of this form to: Pam Hileman, NERCRD, 7 Armsby Bldg., Penn State University, University Park, PA 16802.

Cardholder Name

Fee

Card#

Expiration

Card Type: Visa/Mastercard, Discover, American Express

A block of rooms has been reserved at Sheraton Society Hill Hotel at the rate of $179/night. To reserve a room call (215) 238-6000 and mention Penn State Connecting Communities. The cut-off date for making reservations is May 12, 2006. Hotel information can be found at: http://sheraton-philadelphia.felcor.com/
Limited travel support scholarships will be available. Award amounts will be determined after the conference has been held. To apply for a travel scholarship, please fill in the information below.

Name

Estimated Travel Expense

When you have completed every section of the form, you can either send the form to the Northeast Center, or click reset to clear the form and start over.

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