Form 1 OCRPL Outreach and Engagement Activities Registration Fo

NIMH Office of Constituency Relations and Public Liaison (OCRPL) Outreach and
Engagement Activities Registration
OMB # 0925-0740
Expiration Date: 05/2019
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0740). Do not return the completed form to this address.

(EVENT NAME) Registration Form
(EVENT DATE)
(EVENT LOCATION)
Please provide the contact information requested below to register for the (EVENT NAME) meeting. A
confirmation email will be sent to the email address provided following the submission of this form. Online
registration is available until (DATE & TIME). On-site registration will be available thereafter.
* Indicates required information.

Contact Information
First Name *:
Last Name *:
Degree:
Title *:
Organization *:
Street Address *:
Suite / Apt / Box:
City *:

State *:
Zip *:
Phone *:
E-mail address *:

Meeting Attendance
(MEETING DATE & TIME)
(MEETING LOCATION)

Lunch Option
Due to the closure of the (MEETING LOCATION) cafeteria, a box lunch will be available at a cost of
(COST) from (VENDOR). It will include (DESCRIPTION OF VENDOR OPTIONS).
Please make your choice and check the appropriate box:
(OPTION 1)
(OPTION 2)
(OPTION 3)
I do NOT wish to purchase a box lunch

Payment will be collected onsite at the meeting, only cash will be accepted and the exact amount would
be appreciated.

Lodging
Participants requiring lodging may reserve a room at (LODGING NAME) located at (LODGING
ADDRESS).

Accommodation

Individuals with disabilities who may require sign language interpreters and/or reasonable accommodation
to participate in this meeting should indicate the requested accommodation in the space provided below.
Requests should be made at least 10 days in advance of the meeting.
I request the following accommodations:

Submit

Clear

Travel Information
Driving directions to the (MEETING LOCATION).
Metrorail directions to the (MEETING LOCATION) Additional information on the Metrorail system
can be found at http://www.wmata.com/.

Contact Person for Comments or Special Accommodations
Phyllis Quartey-Ampofo at 301-443-8530 or [email protected]