This Reservation Form must be received by October 20, 2004.

1.   Social Security Number__________________________________________________________

2.   Member’s Full Name ____________________________________________________________

      Mail Confirmation letter to: ____ Member or ____ Employer

3.   Address ______________________________________________________________________

4.   City ___________________________________________Zip____________________________

5.   Employer _____________________________________________________________________

6.   Phone (______) ________________________________________________________________

7.   City or Town Where You Work ____________________________________________________

8.   Job Classification _______________________________________________________________

9.   Disability Accommodations      □ Auditory     □ Mobility         □ Visual           □ Other

10. Will Spouse/Partner Attend?: _____ No _____ Yes  (If Yes, complete below)

      Is Spouse/Partner a CalPERS member?:

       ___ No ___ Yes  (If Yes, continue)

      Spouse/Partner’s Name: _________________________________________________________

      Spouse/Partner’s Employer: ______________________________________________________

      Spouse/Partner’s Social Security Number: ___________________________________________

Please mail this Reservation Form to:

Orange Regional Office

500 No. State College Blvd                                                                  SIGNAL HILL AREA

Suite 750                                                                                              November 17-18, 2004

Orange, CA 92668

Telecommunications Device for the Deaf – (916) 326-3240

(888) 225-7377; FAX- (714) 939-4701