Peace Corps

Coverdell World Wise Schools Conference

Registration

To reserve a place at the conference, please fill in your information below.

* indicates a required field.

First name*
Last name*
Address1
Address2
City
State
ZIP Code
Phone
Fax
E-mail*

Affiliation: (school, government agency, etc.)


Questions or additional information:

OMB Approval Number 0420-0541
Expiration Date: 12.04.10

PC-963

Privacy Act Notice: Authority to request this information is the Peace Corps Act {22 U.S.C. §2501 et seq.} (as amended). This information will be used in processing your registration for the Coverdell World Wise Schools Conference. This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and in the Federal Register at 65 Fed. Reg. 53,722 (September 5, 2000) and 50 Fed. Reg. 1950, 1962 (January 14, 1985) regarding Peace Corps systems of records. Disclosure of this information is voluntary. Failure to provide sufficient information may preclude your consideration for the Coverdell World Wise Schools Conference.

Paperwork Reduction Act Burden paragraph per 5 CFR Part 1320(b)(3): This is a voluntary information collection. The estimated burden for completing this form is 10 minutes. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to: the director of Peace Corps Coverdell World Wise Schools, 1111 20th Street, NW, 2nd Floor, Washington, D.C. 20526 and to the Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.

Paul D. Coverdell World Wise Schools

Registration

E-Newsletter

Get Acrobat