First Recruiter

* First Name
* Last Name
* Title
* School/Department
* College/University
* Campus or Street Address 1
Campus or Street Address 2
* City
* State/Province
* Zip + 4/Postal Code
* Telephone Number    [e.g., 555-555-5555]
* E-mail Address

Second Recruiter

First Name
Last Name
Title
School/Department
College/University
Campus or Street Address 1
Campus or Street Address 2
City
State/Province
Zip + 4/Postal Code
Telephone Number [e.g., 555-555-5555]
E-mail Address

* Date of Registration

	I wish to register ONLY for the Forum at CSU Channel Islands on Saturday, April 17, 2010. Fee = $450.
	I wish to register for BOTH the Forum at CSU Channel Islands on Saturday, April 17, 2010, and the Forum at Sacramento State University on Saturday, October 16, 2010. Fee = $750.
	I am unable to attend, but please keep me on your mailing list for future Forums.

Payment Options

* Payment options: Select a payment Check Credit Card Purchase Order

Please invoice my institution.

If you wish to pay by CHECK, please make checks payable to:
CALIFORNIA FORUM FOR DIVERSITY (FED ID# 95-6106694). Mail your payment to Anastasios Chassiakos, Director, California Pre-Doctoral Program, CSU Office of the Chancellor, 401 Golden Shore, 6th Floor, Long Beach, CA 90802-4210.

If you wish to pay by CREDIT CARD, please call Anastasios Chassiakos at (562) 951-4774 or Sara Zaragoza-Oliva at (562) 951-4775. They will take down the necessary information over the telephone. In that way (and in accordance with our new security policy), your credit card information will never be recorded in a computer database.

Registrations received after the due date will be accommodated only if space is available and cannot be included in the printed Guide to Recruiters provided to all students attending. Should the recruiter fair area fill to maximum capacity prior to the due date, the registration process will be closed immediately and all subsequent requests for registration will be returned.

For questions, please contact Anastasios Chassiakos at achassiakos@calstate.edu or (562) 951-4774.