Select Region V Region VI Region VII * (24 hour format) Select your Region YesNo YesNo Can your business information be used for conference activities? Can your local stay and contact information be made available to conference planners? Arrival Time Departure Time Select Vegetarian Diabetic Kosher Meal Accomodation YesNo EMERGENCY CONTACT INFORMATION Name Phone If no, will stay at Do you require Lodging? Sign Language InterpreterWheel Chair AccessibilityOther YesNo Please specify Please describe your need in order to particpate SPECIAL NEEDS Departure Date Arrival Date Please enter your travel date information(MM/DD/YY) Please select your mode of transportation Select Air Drive Local Not Decided TRAVEL INFORMATION Are you an invited speaker? Relationship   Email Address ---- Male Female Gender   If you are not affiliated with a school, please indicate the HBCU you are partnering with Mobile (For Badge) Preferred Name           REGISTRATION PROFILE * * * * ---- Mr. Mrs. Ms. Dr. Fax ---- AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY (123-456-7890) State Zip Code Phone Morning Evening Preferred Address Line 2 City Title Department Institution/Organization Preferred Address Line 1 Last Name Middle Initial First Name Mr./Mrs./Ms./Dr. Online Registration *