Convention Registration Form

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Registration Fee: $125.00 per person
Includes Continental Breakfast, Banquet Dinner, Music, Dance and Conference Materials

 

Name:

Title:

Organization:

Mailing Address:

Mailing Address:

City:

State (region):

Zip (postcode):

Country:

Email:

Phone:

Fax:

If more members of your family, apart from yourself, intend to attend please list their names Below:
1:

2:

3:

4:

5:

6:

7:

8:

             

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SOMALILAND POLICY AND RECONSTRUCTION INSTITUTE
520 S. Virgil Avenue, Suite 402 Los Angeles, CA 90020 (213) 385-8917
Email: ssamater@aol.com