ACSP-AESOP 4th JOINT CONGRESS Faculty Women’s Interest Group (FWIG) July 9, 11:15am ~ Wednesday, Luncheon Registration Form PERSONAL INFORMATION I am Faculty… Affiliated with ACSP Member School Affiliated with AESOP Member School Other ____________________________ I am a Student… Student from ACSP Member School Student from AESOP Member School Student Other __________________________________________ I require: Vegetarian Meals Vegan Meals Handicap Accessibility Other Accommodation - describe _____________ Return this registration form no later than July 1, 2008: Return by Email as a PDF: Return by fax: Call in Registration: firstname.lastname@example.org 1.850.385.2084 1.850.385.2054 Note: This event may conflict with your scheduled mobile tour. Please double-check Wednesday mobile tour departure times. First Name Institution Department Select One: City ZIP/Postal Code Work Home Cell Last Name Nickname for Badge Home Address Work Address Street Address or PO Box State Country Preferred Email Province Attending Spouse/Guest Name for Name Badge REGISTRATION FEE Faculty Fee Student Fee I’m requesting a student “colleagueship” ticket $35 $20 $0 GRAND TOTAL $ ___________ PAYMENT VISA Name on card MasterCard Expiration / Signature Credit Card # ____________ - ____________ - ____________ - ____________ *Security code * Additional security measure sometimes required by the credit card processor. The code is the last three digits in the signature box on the back of your card .
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