Date: _____________
Name: ________________________________________________________________________
	(Last)	(First)	(Middle)
Title: _________________________________________________________________________
Spouse's Name: ________________________________________________________________
Mailing Address: _____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Telephone:	(____)__________________________ Home
	(____)__________________________ Office
Fax:	(____)__________________________
Company Affiliation: ____________________________________________________________
Address: _____________________________________________________________________
Connection with Bahrain, if any (current or past):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Special Interests:_____________________________________________________________
_____________________________________________________________________________
Amount enclosed:
(__) $25	(__) $50	(__) $15	(__) $500
Individual	Couple	Student	Corporate

*Please print and fax/mail the completed application with your check to the address above