GRAND CASINO BILOXI BAY VIEW

265 Beach Blvd. - Biloxi, MS, US 39530

Telephone (800) WIN2WIN  or (800) 946-2946

May 13, 14, & 15, 2004

CONVENTION REGISTRATION FORM

Make reservations directly with the hotel – Rate $115 per night (Single/Double)

Please type or print

Mr./Mrs./Ms: ____________________________________  Badge: ________________

                                                (Sertoman)                                                                            Name you wish on Badge

Spouse/Guest: ___________________________________   Badge: _________________

          Circle

Address: ________________________________________  City:  __________________

State:  ___________  Zip:  ________________  Phone:  ____________________

Sertoma Club: ___________________________   District: ________________________

Current Office Held (Circle one - Reg/Distr/Club): ______________________________

Life Member:  Yes - No                        Is this your first Regional Convention:  Yes - No

Email Address: __________________________________________________________

Confirmation and any updates will be sent to the email address listed.

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                                                                                                         Number Required                                    Total Cost

Full Convention Registration                             $ 100.00   X  _________________   =  ________________

(Postmarked prior to 4/15/2004)                                                            

Full Convention Registration                             $120.00  X __________________  =  ________________

(Postmarked 4/15/2004 or later)

Golf Tournament                                                  $ 60.00  X __________________  =  _________________

Additional individual tickets:

Thursday Welcome Party                                   $ 25.00  X  _________________  =  _________________

Friday Awards Breakfast                                    $ 25.00  X  _________________  =  _________________

Saturday G/G/R/B Coat - LM. Breakfast           $ 15.00  X  _________________  =  _________________

Saturday Evening Installation Banquet           $ 50.00  X  _________________  =  _________________

                                                                                                                TOTAL            =  _________________

Make checks payable to:                    Sertoma 2004 Regional Convention

Send your checks to:                           P.O. Box 4272  -  Laurel, Mississippi 39441

Full registration includes the following:  Project Lead (held at Regional-Coordinated by the Tragons), Thursday Shrimp/Crawfish Party, Friday Awards Breakfast, and Saturday Installation Banquet

Additional information visit http://users.ilnk.com/sertoma/