Monday, September 16, 2013


REGISTRATION FORM 14th


NAME TITLE


ORGANIZATION ADDRESS CITY


PHONE E-MAIL


FAX


Please indicate your registration type*: $350 Early Bird (Deadline: August 12, 2013) $350 MCCA** and ACC members/FANs/Pathways Sponsor Rate $350 Group Rate (Rate is per person; 3+ from the same organization) $450 General Registration (After August 12, 2013)


Add a ticket to attend MCCA’s Diversity Honors Gala at Alice Tully Hall, Lincoln Center on Tuesday, September 17, 2013


$625 MCCA Diversity Honors Gala, Non In-House Counsel $475 MCCA Diversity Honors Gala, In-House Counsel Ticket $450 MCCA Diversity Honors Gala, Member/FAN Ticket $375 VIP Reception Only


$ Total Amount Note: Registration is NOT CONFIRMED until payment has been received.


QUESTIONS? SPECIAL REQUESTS? EMAIL education@mcca.com


CHECK (Enclosed) CREDIT CARD NUMBER


PRINT CARDHOLDER’S NAME CARDHOLDER’S SIGNATURE BILLING ADDRESS


VISA AMERICAN EXPRESS MASTERCARD EXP. DATE Annual Creating Pathways to Diversity® Conference | Marriott Marquis Hotel | New York, NY


14th


Annual


STATE


ZIP CODE


3 WAYS TO REGISTER ONLINE


www.mcca.com (credit card only)


FAX form to (202) 739-5999


MAIL form and check to: Minority Corporate Counsel Association 1111 Pennsylvania Avenue NW Washington, DC 20004


Check here if billing address is the same as listed in contact information


*By submitting this form, you agree to MCCA’s cancellation policy and grant MCCA the right to photograph, fi lm, and use your likeness and voice in MCCA related publicity and advertising. MCCA is a not-for-profi t organization classifi ed under section 501(c)(3) of the Internal Revenue Service Code. MCCA’s tax identifi cation number is 13-3920905.


** MCCA corporate members receive up to 3 complimentary registrations to attend the Creating Pathways to Diversity® Conference. Contact a staff member at education@mcca.com for details.


PAYMENT METHOD


REGISTRATION ITEMS


CONTACT INFORMATION


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