Fort Collins, Colorado, USA - July 11–18, 2013 – Registration Form
Please fax this completed form to Dr. Robert P. Ellis. Fax (confidential number): 970-204-6684
Please type or print the following Registration information:
Name:___________________________________________________________
Affiliation:_____________________________________________ Department:_________________________________________
Affiliation Address: __________________________________________________
City:________________________ State:_______ Zip/Country:_______________
Home Address (use if no dept/affiliation address):__________________________________________________________
E-mail:(type or print)_________________________________________ Phone:______________________
Method of Payment: (select one) check____ credit card____ Cash____
REFUND POLICY
*Payment by check: Checks should be made out to "Biosafety and Biosecurity Course ". Send payment to:
Dr. Bob Ellis
141E General Services Building, Campus Delivery 6021
Colorado State University
Fort Collins, CO USA 80523-6021
*Payment by cash: Make arrangements with Dr. Ellis to pay cash on–site prior to course session attendance.
*Payment by credit card: (Please fill in the following information)
Credit Card Number __________________________________________________ Expiration Date _____________________
Verification No. __________(3 digit number which may follow a 4 digit number and appears on the signature strip on the back)
Name on the card _______________________________________________________________________________________
Street Address _______________________________________________ Zip/Country Code ___________________________
Type of credit card (Visa, MasterCard, American Express, or Discover) ____________________________________________
Type of credit card (Visa, MasterCard, American Express, and Discover Card): _______________
What sessions are you paying? Please check one of the following options:
a) Animal + General Sessions ($1600) ________
b) Plant + General Sessions ($1600) ________
c) Animal + General + Plant Sessions ($1900) ________
Please include a Confidentiality Notice on the Cover Sheet when you fax your personal information. You may use the following statement:
"Confidentiality Notice — The content of this fax contains confidential information, intended only for the person(s) named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or any other use of this information is strictly prohibited. Please destroy the information immediately and all copies thereof. If you have received this fax in error, please notify us by telephone at 970-491-8268."
REFUND POLICY: Registration fee full refund less 5%, if requested within 35 days of annual meeting; 50% refund from 34–15 days before annual meeting; no refund if requested 14 days or less before annual meeting.