Puerto Rico TESOL 39th Annual Convention and the 11th CA & CB Regional Conference

Central American and Caribbean Basin TESOL Affiliates

Friday and Saturday, November 16-17, 2012

Journey into English as a Global Language: Embracing Diversity

Intercontinental Hotel Resort and Casino, Isla Verde, PR www.puertoricotesol.org ~ email: info@puertoricotesol.org

PRE-REGISTRATION FORM
(Please read and print clearly)

Last Names: Membership ID #: Mailing Address: City: Phone (home): State/Country : Cellular: Expiration date:

First Name(s): Chapter:

Zip Email:

Type of institution in which you work: Level: Elementary

Secondary

Public Private Workplace_________________________________ Higher Education Administration

Convention Fees *Use separate form for each registrant. Payment through a purchase order or institutional check, must include a separate registration form for each individual. Purchase orders must list each attendees name and have an original signature.

Please check the appropriate option.

One day with lunch Both days with lunch Friday November 16, 2012 Preregistration
Before: Sept 19, 2012

One day with lunch Saturday, November 17, 2012 Preregistration

Before: Sept 19, 2012

Preregistration
Before: Sept 19, 2012

On Site
Lunch not guaranteed

On Site
Lunch not guaranteed

On Site
Lunch not guaranteed

Member NonMember *Student or Retired members *Student or retired NonMember

$140 $180 $110 $135

$180 $210 $130 $155

$90 $120 $80 $120

$120 $150 $110 $140

$90 $120 $80 $120

$120 $150 $110 $140

Mail Payment & Registration form to:

PRTESOL CONVENTION P. O. BOX 366828 SAN JUAN, PR 00936-6828

If you are joining or renewing, fill out a membership form and attach it to this form with a separate check. DO NOT INCLUDE MEMBERSHIP FEE

**Please note: Rate applies for full-time students only (twelve credits per semester or more) with a copy of class program.

TOTAL AMOUNT INCLUDED:

Payment Information: Please do not mail cash. Prepare your checks or money orders payable to PRTESOL. Bank:_______________________________
P RT E S O L refunds. P RT E S O L subject to w i l l n ot h o n o r r e q u e st s f o r A l l c h ec ks r e t u r n e d t o d u e t o l a c k of f u n ds a r e a $15 penalty fee.

Money Order

Check Number: _____________________

Amount $_________ Received by:

FOR OFFICE USE Date Received _____________ _____________________