Event Registration Signup Form
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1Event
R egistration
S ignup
F orm
Event: __________________________
Date: __________________________
Program and lodging information
Full Name: _______________________________________________ (First name for badge)____________________________
University/Organization: ___________________________________________________________________________________
Preferred Mailing Address:__________________________________________________________________________________
City: ________________________________ State/Province: ______________________ Zip/Postal Code: _________________
Country: _____________________________ Telephone: (______)__________________ Fax: (______)____________________
Email: __________________________________________________________________
CONFERENCE FEES
Registration Fees
1.
(All fees listed in U.S. Funds.) Includes: ________________________________________________________________
P
:
FEES
LEASE CHECK APPROPRIATE REGISTRAION FEE
___________________________________
r $_______
___________________________________
r $_______
___________________________________
r $_______
___________________________________
r $_______
$ ____________
TOTAL
2.
Indicate tour interest(s):
FEES
___________________________________
r $_______
___________________________________
r $_______
___________________________________
r $_______
$ ____________
TOTAL
3.
Payment
METHOD
Check or Money Order must be in U.S. funds payable to: _____________. There will be a $____.00 fee charged on checks returned
by the bank due to insufficient funds. Registration confirmation/receipt and further information will be mailed.
Please check appropriate box:
r
Check
r
Money Order
r
VISA
r
MasterCard
Expiration Date: _____________________
Card #: ____________________________________________________ Print Cardholder Name: ________________________________________
Please mail or fax completed registration form with payment to:
Phone: _____________
FAX:
_____________
Email:
_____________
E-mailing credit card information because security cannot be guaranteed. It is recommended to fax or telephone credit card information.
Cancellations/Changes and Refunds: Fees for missed meals, late arrivals, and early departures will not be refunded. Fees will be refunded,
less a processing fee, if cancellation or change resulting in a refund is received in writing no later than _____________________. After that date,
fees are non-refundable. All refunds will be processed after the conference. Substitutions are allowed at no charge.
__________________________________________
Signature
__________________________________________
Print Name
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