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Conference Registration Form

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					                                       Conference Registration Form
TIME-2004, July 15th to 18th, Montréal, Canada
See http://time-2004.etsmtl.ca for more information.
Type in the requested information and send the completed form to:
                           Gilles Picard (TIME-2004 Conference)
                           École de technologie supérieure
                           1100 rue Notre-Dame Ouest
                           Montréal, Canada
                           H3C 1K3

Conference Delegate Information

Title : ____ First Name : ____________________ Last (family) Name: ____________________________

e-mail: __________________________________________
Institution or Company: ____________________________
Department: _____________________________________
Mailing address:     ___________________________________________________
                     ___________________________________________________
                     ___________________________________________________
Phone/Fax: ___________________________________

Accompanying Person(s) List the names of all persons accompanying the conference delegate at Wednesday’s
welcome reception, Friday’s excursion, and Saturday’s banquet dinner :
         _______________________________________________________________

Registration fees for conference delegates cover admission to all presentations and workshops, lunches and coffee
breaks as well as Wednesday’s welcome reception, Friday’s excursion, and Saturday’s banquet dinner.
Registration fees for accompanying persons cover Wednesday’s welcome reception, Friday’s excursion, and
Saturday’s banquet dinner.

In order to help us plan sufficient resources, we ask that you fill in the following:

  I plan to attend Wednesday’s Welcome Reception                YES____            NO____

  Indicate your order of preference for Friday’s excursion (1 st , 2nd and 3rd choice)
                      Montréal Tour                                        ___
                      Rural Québec History - Sugar Shack                   ___
                      History, beer, and Gastronomy in Chambly             ___

  I plan to attend Saturday’s banquet dinner                    YES____            NO____

Vegetarian menus or menus for those with food allergies are available. Indicate any special needs of this sort in the
following space.
                 _______________________________________________________________________

                   _______________________________________________________________________
Registration Fees:
Payment must be in Canadian Dollars ($Cnd)

  Registration for conference delegate
     Early bird, by 2 April: 380 $Cdn (approx. 250 Euro, 290 US$)
     Standard, by 4 June: 420 $Cdn (approx. 275 Euro, 320 US$)
     Late, from 5 June: 460 $Cdn (approx. 300 Euro, 350 US$) ......................................______$Cnd
____ Registration for accompanying person(s) :
       Early bird, by 2 April: 190 $Cdn (approx. 125 Euro, 145 US$)
       Standard, by 4 June: 210 $Cdn (approx. 137 Euro, 160 US$)
       Late, from 5 June: 230 $Cdn (approx. 150 Euro, 175 US$) ......................................______$Cnd

Total...........................................................................................................................................______$Cnd

Payment:

Registration fees must be paid in Canadian Dollars. Confirmation of registration will be sent to you, be e-mail (or by
letter), within 10 days of receipt of payment. If, for reasons beyond the control of the organizers, the symposium
should be cancelled, registration fees will be refunded minus a minimal handling fee for registration.

Please ensure you indicate the correct registration fees, consistent with the date of registration. The delegate’s name
and the mention TIME-2004 must appear on all cheques or transfers. The delegate must cover any costs related to
cheques or money transfers.

Total payment of _______$Cnd (registration fees for all participating persons) by the following method:

  Transfer of the above amount to the
       National Bank of Canada
       600, de la Gauchetière Street West
       Montréal, Québec, Canada
       H3B 4L3

            Payable to: École de technologie supérieure (TIME-2004)
            Account number 00011-04-160-21
            Swift code: BNDCCAMMINT            ABA: 026009797

  By Cheque, in Canadian funds, payable to:
       École de technologie supérieure (TIME-2004)

  By credit card. Check off or circle one of the following:                                           Mastercard ____                        Visa ____
       (payment will be charged in Canadian funds)
            Credit card number:                    ______________________________
            Expiration date:                       _________

            Signature:                _________________________
            Date:                     _________________________


Comments:
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posted:7/26/2011
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