FORM # 2 PEF Health and Safety Conference Registration

REGISTRANT INFORMATION

Name of Registrant:_______________________________________________ Title:___________________

Member ID # (PEF members only):______________________________ q Male q Female

Affiliation: q PEF q CSEA q Management q Other:_______________________

Agency Name:______________________________ PEF Division #:_________________________

Work address:____________________________________________________________________________________

Home address (PEF members only): ____________________________________________________________________

Work Phone: ( )_____________________ Home Phone (PEF members only): ( )_________________

HOUSING INFORMATION

Name of Roommate:________________________________________________________________________________

Telephone number of roommate: ( )_________________________________________________________________

Room Preference: q Non-Smoking q Smoking

Have you confirmed with this roommate?: q Yes q No

Select a roommate for me: q

I will be requesting a single room: q

ROOM CHARGES

Double room (per night, tax included): $110.00 (or $55.00 per registrant)

q Thursday q Friday

Single room (per night, tax included): $110.00

q Thursday q Friday Total amount due: ___________________

MEAL RESERVATIONS

Meal prices per day (tax and gratuity included):

Breakfast: $12.00 Lunch: $14.00 Dinner: $24.00

I will need meals for:

Thursday: q Dinner

Friday: q Breakfast q Lunch q Dinner

Saturday: q Breakfast

Please return this form by Danielle Little-Thomson

December 20, 2002 to: NYS Public Employees Federation Registration Fee: $35.00

H&S Conference Registration