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					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: kdd@acsp.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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