REGISTRATION FORM

							                                             REGISTRATION FORM
                                  44th Annual Symposium STC, December 3-4, 2012
         New Residence Hall at McGill University, 3625 Avenue du Parc, Montreal, Quebec, Canada

                 Frontiers of Toxicology: New Questions, New Methods and New Approaches

Please print

Name :                                                    Telephone:

Address:                                                  Fax:

                                                          Email:
FEES (Includes all taxes)

       Member                                                                  $295           $

       Non-member                                                              $450           $

       Student member (postgraduate or postdoctoral)                           $90            $

       Student non-member (postgraduate or postdoctoral)                       $140           $

       I will present a poster (abstract due by October 12th)                  Yes     No

       I will attend the Careers in Toxicology Session on                      no charge
       December 2nd

       I will attend the workshop after the regular sessions on                no charge
       December 3rd

       I will attend the President’s Reception and Awards                      no charge
       ceremony after the Workshop on December 3rd
       (* try our ToxQuiz…prizes given!)

                                             TOTAL                             $



Registration deadlines: Poster presenters and student award applicants: Abstracts and registration
forms due Friday October 12th; All participants: registration forms due Monday, November 19th. Payment
deadline: Monday, November 19th. (Note: On-site registration and payment may be available for an
additional $50 fee BUT we encourage you to register ahead of the meeting to avoid delays on the first
morning).

Type of payment

cheque (Please make your cheque payable to STC)
credit card        MasterCard     VISA     AmEx (do not fill-in if paying online)

                  Card #: ________________________________                 Expiration Date: _____________

                  Signature : _____________________________                Date : _____________________

Please send your cheque and/or form to: STC – P.O. Box 55094, Montréal, Québec H3G 2W5 online secure
payment
To access our online secure payment, click on the link Secure Online Payments on the home page of our web
site www.stcweb.ca (please also send your completed registration form by email to stcsecretariat@mcgill.ca).
                                    (GST: R127067122, QST: 1013467125)