Biosafety
and Biosecurity Training Course Registration Form
2010 BIOSAFETY and BIOSECURITY TRAINING COURSE - July 8-15
Please fax this completed form to Dr. Robert
P. Ellis
Fax: 970-491-4804
MasterCard, VISA, American Express, and Discover Credit
Cards are accepted.
Registration and Payment Form
Please type or print the following information:Name:__________________________________________________________
Affiliation:_______________________________________________________
Department:_______________________________________________________
Address:________________________________________________________
City:________________________State:_______Zip/Country:______________
Phone:______________________________Fax:________________________
E-mail:(type or print)_____________________________________________________
Method of Payment: (select one) check________ credit card________
REFUND POLICYPayment 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 80523-6021
Payment by credit card: (Please fill in the following information)
Credit Card Number: ________________________________________
Expiration Date: __________
Verification No.(This is the 3 digit number - it may
follow a 4 digit number- which appears on the signature strip on the back
of the card): ______
Name on the card: _______________________________________
Street Address: _________________________________________
Zip/Country Code: _______________
Type of credit card (Visa, MasterCard, American Express, and Discover Card): _______________
What are you paying? Please check one of the following options:
a) Animal + General Sessions ($1400) ________
b) Plant + General Sessions ($1400) ________
c) Animal + General + Plant Sessions ($1700) ________
Amount you are paying: _______________
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 970-491-6729."
REFUND POLICY: Registration fee full refund, less $20, 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.