Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Are you, a relative or family member a former member of the Black Panther Party?  yes__ no___.

Chapter affiliation ____________________________________ 

You will be attending the Dinner  yes__ no__ and the Film Festival  yes___ no ___.     

         Fees: 

         Dinner - $25 per person multiply by # of guests             ____ = ______

              Film Festival - $10 per person multiply by # of guests   ____ = _______  

                Total fees due                                                                             _______

Please make checks payable to: It's About Time

Mail to:  It's About Time, PO Box 221100,  Sacramento, CA 95822

For more information call: (916) 455-0908 or