Thank you for your interest in the 2009 Black Leadership Conference. If you would like to register for the conference, please complete the following form.

First Name:
Last Name:
City/State/Zip:	,
Email Address:
Phone Number:	()
Age:	Under 15   15-17   18-20   21-23   24-26   27-30   31-35   36-40   Over 40
Are you still in school?	Yes   No
If Yes what school, major, and degree are you pursuing?
School Name:
Major:
Degree Pursuing:
Highest Degree Obtained:	None   High school Diploma   BS/BA   Masters   PhD
Number of prior Black Leadership Conferences
Is your employer or school sponsoring your attendance at this event?	Yes   No
Who referred you to the conference?
May we contact you about your conference experience?	Yes   No
Please submit your resume:	(word document)
Registration Type:	Full Conference Admission $15.00 for Ga. Tech Students $40.00 General Admission Friday Conference Admission $25.00 One Day Admission Saturday Conference Admission $25.00 One Day Admission **Dr. Cornel West Sunday admission is FREE to the public but ONLY CONFERENCE ATTENDEES ARE GUARANTEED PRIORITY SEATING**
Payment	Online