Registration Form
Name:
___________________________________________________
Address:
___________________________________________________
City:
___________________________________________________
State, Zip:
___________________________________________________
Phone:
___________________ Email:
________________________
Fees (Including registration for the conference,
refreshments, and light lunch)
□ $ 20
□ I prefer vegetarian lunch.
Enclosed is my conference fee:
□ Check (payable to Thomas Merton Center)
□ Visa/MasterCard/American Express
Credit Card Number:
__________________________________________________
Expiration
Date:______________________________________________________
3-4 Digit Card Verification
Code:_________________________________________
Cardholder's
Name:____________________________________________________
Cardholder's
Signature:_________________________________________________
Please print and return this form to:
Paul M Pearson.
Thomas Merton Center,
Bellarmine University,
2001 Newburg Road,
Louisville. KY. 40205.