Just for H.E.R.! Registration Form

Please fax completed registration form to (646) 424-9751.

First Name ________________ Middle Initial ____ Last Name ______________________

Company Name ______________________________ Title ________________________

Address ________________________________ City ______________ State ____ Zip ______

Home Phone ______________ Work Phone ______________ Fax Number _____________

Email Address ___________________________________ Date of Birth ________

Martial Status ___________ How many children do you have? _______ Age Range? _______

College ___________________________ Post Graduate _________________________ Profession______________________________________________

Household Income (Please check the appropriate box.)

[  ] $25,000 - $50,000     [  ] $50,000 - $75,000     [  ] $75,000 - $100,000    
[  ] $100,000 - $150,000     [  ] $150,000 - $200,000      [  ] $200,000 - $250,000      [  ] $250,000 and up

How did you hear about Just for H.E.R.!_______________________________________

Are you staying at the Grand Hyatt New York? ____ If not, where? _______________________

Emergency Contact _________________________________ Phone Number _________________

Yes, Register me Now!

[  ]$75 - Early Bird Registration

[  ]$100 - General Registration

[  ]$125 - On-site Registration

Method of Payment

[  ]Check # _________________    [  ]Money Order     [  ]Visa     [  ]MasterCard

Credit Card Number _________________________________ Expiration Date __________

Exact Name on Credit Card_________________________________

Signature ________________________________________________ Date ________

The signature above authorizing Noelle-Elaine Media, Inc. to charge my credit card for the Just for H.E.R.! conference.

Cancellations are subject to a $50 processing fee. Sorry, no refunds after September 30, 2002.

Please fax completed registration form to (646) 424-9751.

Noelle-Elaine Media, Inc.
118 East 28th Street, Suite 207
New York, NY 10016
Tel: 646-424-9750