| Name: |
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| Gender: |
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| Street address: |
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| City, State, Zip code: |
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| Country: |
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| Email address: |
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| Home phone: |
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| Work phone: |
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| Cell phone: |
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| What is your native language? |
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| Do you understand English? |
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| Will you need a translator? |
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| Can you serve as a translator? |
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Roommate preference:
Hostel rooms accommodates 2 - 6 people. If you are
attending the retreat with your spouse, partner or friend,
please note
her/his name here, otherwise we will match you with
a retreatant of your
gender. |
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| Registration fee*: |
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*Refunds, minus $50. service charge, can
only be made until October 15,
2004. After October 15, 2004, refunds are not possible.
Unused funds will
be transferred to the Scholarship Fund.
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| MEMORIAL CANDLES: |
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| In honor of (name/s): |
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| Amount of contribution to Scholarship Fund: |
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| METHOD OF PAYMENT: |
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| 1 .Credit Card: |
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2.
On-line payment |
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3. By check to: |
Hudson River Peacemaker Center |
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mail check to: |
Hudson River Peacemaker Center |
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384 East 149th Street Suite 424
Bronx, N.Y. 10471 USA |
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| 4 Money transfer |
For money transfers directly to the Poland please
use the following /SWIFT/ accounts: |
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. For US Dollars: |
Andrzej Krajewski /AB RETREAT/ |
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PKOPPLPW
14 1240 1138 1787 0000 0207 6036 |
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For Euros: |
Andrzej Krajewski /AB RETREAT/ |
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PKOPPLPW
27 1240 1138 1978 0000 0207 6049 |
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| TOTAL ENCLOSED: |
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Comments:
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