This document appears to be an individual registration form for a Catholic Charities USA conference taking place from March 22-27, 2015 in South Bend, Indiana. It requests information such as name, job title, address, emergency contact and any special needs from attendees. It also provides a list of related Catholic organizations and asks how attendees are affiliated with agencies. Payment information is requested at the bottom.
This document appears to be an individual registration form for a Catholic Charities USA conference taking place from March 22-27, 2015 in South Bend, Indiana. It requests information such as name, job title, address, emergency contact and any special needs from attendees. It also provides a list of related Catholic organizations and asks how attendees are affiliated with agencies. Payment information is requested at the bottom.
This document appears to be an individual registration form for a Catholic Charities USA conference taking place from March 22-27, 2015 in South Bend, Indiana. It requests information such as name, job title, address, emergency contact and any special needs from attendees. It also provides a list of related Catholic organizations and asks how attendees are affiliated with agencies. Payment information is requested at the bottom.
This document appears to be an individual registration form for a Catholic Charities USA conference taking place from March 22-27, 2015 in South Bend, Indiana. It requests information such as name, job title, address, emergency contact and any special needs from attendees. It also provides a list of related Catholic organizations and asks how attendees are affiliated with agencies. Payment information is requested at the bottom.
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Catholic Charities USA
Individual Registration Form
NOTRE DAME - FROM MISSION TO SERVICE | MARCH 22 - 27, 2015 | South Bend, IN DIOCESAN DIRESTOR Job Title: Address: City/State/Zip: Phone: Email: Fax: Emergency Contact (name/phone) Special needs/restrictions Attendee Job Title: Address: City/State/Zip: Phone: Email: Fax: Emergency Contact (name/phone) Special needs/restrictions Attendee Job Title: Address: City/State/Zip: Phone: Email: Fax: Emergency Contact (name/phone) Special needs/restrictions Attendee Job Title: Address: City/State/Zip: Phone: Email: Fax: Emergency Contact (name/phone) How are you related to the Agency? Check this box if you DO NOT want to be included in our Attendee Lists. DIOCESAN DIRECTOR Use the dropdown to find your main Diocesan agency (state, city). If you are not affiliated with a Catholic Charities agency, select Not Applicable. Check this box if you DO NOT want to be included in our Attendee Lists. Attendee 3 Attendee 2 How are you related to the Agency? Check this box if you DO NOT want to be included in our Attendee Lists. Attendee 4 Special needs/restrictions Attendee Job Title: Address: City/State/Zip: Phone: Email: Fax: Emergency Contact (name/phone) Special needs/restrictions Quantity Registration Type Unit Price Total 1 Organization (Agency) deposit $1,000.00 $1,000.00 Total: $1,000.00 Name on Card: Exp. Date: Card Number: Security: Signature: Send completed forms to: Catholic Charities USA 2050 Ballenger Avenue, Suite 400 | Alexandria, VA 22314 Phone: (703) 549-1656 | Secure Fax: (703) 549-1728 Payment Method How are you related to the Agency? How are you related to the Agency? Check this box if you DO NOT want to be included in our Attendee Lists. Check this box if you DO NOT want to be included in our Attendee Lists. Attendee 5 VISA Mastercard My check is enclosed American Express Discover Not Applicable 10163582 - AK - Anchorage 10163583 - AK - Juneau 10163584 - AL - Birmingham 00038390 - AL - Mobile 10163585 - AR - Little Rock 10163586 - AS - Pago Pago 00005299 - AZ - Phoenix (Catholic Charities) 10133020 - AZ - Phoenix (Found. for Sr. Living) 00059166 - AZ - Tucson (Southern AZ) 00040646 - CA - Fresno 00065313 - CA - Los Angeles 00034227 - CA - Oakland (East Bay) 00023508 - CA - Sacramento 00065203 - CA - San Bernadino 00005389 - CA - San Diego 00043127 - CA - San Francisco 00005627 - CA - San Jose (Santa Clara) 00038391 - CA - Santa Ana (Orange County) 00034066 - CA - Santa Rosa 10369477 - CA - Seaside (Monterey) 10150241 - CA - Stockton 10163594 - CO - Colorado Springs 10139899 - CO - Denver 10161787 - CO - Pueblo 00022379 - CT - Bridgeport (Fairfield) 00085445 - CT - Hartford 10163595 - CT - Norwich 00005418 - DC - Washington 10148272 - DE - Wilmington 00075253 - FL - Jacksonville (St. Augustine) 00005427 - FL - Miami Shores 10162845 - FL - Orlando (Central FL) 10093927 - FL - Palm Beach 00038395 - FL - Pensacola (NW Florida) 00038394 - FL - St. Petersburg 00074495 - FL - Venice 00038421 - GA - Atlanta 10163968 - GA - Savannah 10144625 - GU - Barrigada (Hagatna) 00038396 - HI - Honolulu 10369904 - IA - Davenport (Social Action) 00034765 - IA - Des Moines 00075264 - IA - Dubuque 00035410 - IA - Sioux City 10163969 - ID - Boise 10377047 - IL (Belleville) (Catholic Charities of So. IL) 00005286 - IL - Chicago 10092399 - IL - Joliet 10163970 - IL - Peoria 00020888 - IL - Springfield 00005269 - IN - Evansville 00005429 - IN - Ft Wayne 00038397 - IN - Gary 10372188 - IN - Indianapolis 00036755 - KS - Dodge City 00036893 - KS - Kansas City (NE Kansas) 00065188 - KS - Salina 00005360 - KS - Wichita 00038399 - KY - Covington 00005425 - KY - Lexington 00036857 - KY - Louisville 10163990 - KY - Owensboro 10163991 - LA - Alexandria 00005423 - LA - Baton Rouge 00058662 - LA - Houma 10370498 - LA - Lafayette 10163993 - LA - Lake Charles 00058220 - LA - New Orleans 10431202 - LA - Shreveport 00035408 - MA - Boston 00074964 - MA - Fall River 10165052 - MA - Springfield 00072210 - MA - Worcester 00005629 - MD - Baltimore 10092778 - ME - Portland 10370483 - MI - Detroit 00036870 - MI - Grand Rapids (West MI) 00005288 - MI - Kalamazoo 00065076 - MI - Marquette (Upper Peninsula) 00038401 - MN - Minneapolis (St. Paul) 10391345 - MN - New Ulm 00012131 - MN - Saint Cloud 00075266 - MN - Winona 10165271 - MO - Jefferson City (Central & Northern MOi) 00038402 - MO - Kansas City 00023372 - MO - Saint Louis 10412461 - MO - Springfield (Southern MO) 10478696 - MP - Karidat Social Services 00036895 - MS - Biloxi 10093276 - MS - Jackson 10165272 - MT - Helena 10142121 - NC - Charlotte 10092401 - NC - Raleigh 00065075 - ND - Fargo 00036979 - NE - Omaha 10165274 - NJ - Camden 00005334 - NJ - Newark 00084093 - NJ - Paterson 00005604 - NJ - Perth Amboy (Metuchen) 10149610 - NJ - Trenton 10145767 - NM - Albuquerque (Santa Fe) 10129581 - NM - Gallup 10370188 - NM - Las Cruces 00005535 - NV - Las Vegas (Southern NV) 10165273 - NV - Reno (Northern NV) 00038403 - NY - Albany 00034792 - NY - Brooklyn 00005008 - NY - Buffalo 00036869 - NY - Hicksville 10093926 - NY - New York 00035407 - NY - Ogdensburg 00036858 - NY - Rochester 10153832 - NY - Syracuse 00064801 - OH - Cincinnati (Southern OH) 00038407 - OH - Cleveland 10162846 - OH - Columbus 00005410 - OH - Dayton (Miami Valley) 10165294 - OH - Steubenville 00034764 - OH - Toledo 00034259 - OH - Youngstown 00033934 - OK - Oklahoma City 00065229 - OR - Portland 00005290 - PA - Allentown 10165296 - PA - Altoona 00065465 - PA - Greensburg 00043538 - PA - Harrisburg 00005301 - PA - Philadelphia 00034228 - PA - Pittsburgh 00038410 - PA - Wilkes Barre (Scranton) 10165327 - PR - San Juan 10165297 - RI - Providence 00035404 - SC - Charleston 00065220 - SD - Rapid City 10136687 - TN - Knoxville (East TN) 00007600 - TN - Memphis 00026447 - TN - Nashville 00005333 - TX - Amarillo 10146072 - TX - Austin (Central TX) 10165318 - TX - Beaumont (Southern TX) 10165320 - TX - Corpus Christi 00005303 - TX - Dallas 00015248 - TX - Fort Worth 00023371 - TX - Houston (Galveston) 10369905 - TX - Laredo 00038411 - TX - Lubbock 10165321 - TX - Odessa (San Angelo) 00005851 - TX - San Antonio 10165319 - TX - San Juan (Brownville) 10369484 - TX - Tyler 00072500 - UT - Salt Lake City 10153534 - VA - Arlington 00005294 - VA - Richmond 00005296 - VA - Virginia Beach 10165328 - VI - St. Thomas 00035023 - VT - Burlington 10092405 - WA - Seattle (Western WA) 00058515 - WA - Spokane 00005417 - WA - Yakima 10165323 - WI - Green Bay 00072637 - WI - La Crosse 10092783 - WI - Madison 10142123 - WI - Milwaukee 00075145 - WI - Superior 00036902 - WV - Wheeling 00005302 - WY - Cheyenne Not Applicable Board Member Employee (branch office) Employee (main agency) Volunteer Select one (optional) 1 Financial Stability 2 Business Venture Services 3 Children's Assessment Center 4 HOMES Housing Opportunity Model 5 Casa Housing Property 6 Development Office Tracks Available Track 1 - Advocacy Track 2 - Direct Service Track 3 - Immigration Track 4 - Parish Leadership Development Not Applicable 10442768 - Catholic Charities of Missouri, LLC 10478366 - Catholic Legal Services Archdiocese of Miami, Inc. 10408108 - Center of Concern 10471047 - Cross Catholic Outreach 10429299 - Dominican Sisters - Grand Rapids 10485935 - Family Crisis Center, Inc. 10143371 - Society of the Divine Savior 1/16/2014 - agency list last updated (kco)