CRWAD Meeting Registration Form
Pleas print this form, fill
it out, and Send it with payment to Dr. Robert P. Ellis
(Must be postmarked by November 9 for pre-registration –
Pre-Registration Will Close November 10; On-site is Available)
The Annual CRWAD Meeting will be held December 2 – 4, 2012 at the Chicago Marriott, Downtown Magnificent Mile, Chicago, Illinois. Presentations will conclude by 1 pm Tuesday afternoon, December 4. The attendance is limited to CRWAD members, participants on the program and guests invited by the Council. Please type or print the following information:
Name:_______________________________________________________________________________
Affiliation:____________________________________________________________________________
Department of Affiliation: ________________________________________________________________
Address of Affiliation or Personal? (circle one) :_______________________________________________
City:________________________________
State:________ Zip/Country:_________________________
Phone:_______________________________________Fax:____________________________________
E-mail: (type or print)____________________________________________________________________
Emergency Contact:_____________________________________Phone:__________________________
Please note: You are not a member until
you have applied for membership and the Council has granted membership.
Non-members must register as either a guest, or a post–doc, or a fulltime student.
*Abstracts are available on-line at the Meeting Planner and Itinerary Builder.
| Approved Member Meeting Registration: $100 (includes Program) | ________________ |
| Member: 2012 Dues $70.00 (Dues do not cover registration) | ________________ |
| Unpaid Dues: $70.00 per past year | ________________ |
| Fulltime Student/CRWAD Student Member: $60.00 (includes Program) | ________________ |
| Post–Doc or Resident: $75.00 (includes Program) | ________________ |
| Guest and/or Member Applicant: $250.00 (includes Program) | ________________ |
| Proceedings Booklet (includes Abstracts and Program): $25.00 at on–site $30 if mailed to North America; $40 if mailed to outside of North America |
________________ |
Total Amount Enclosed (US funds only): |
________________ |
Make check payable to CRWAD. Send
payment to Dr. Robert P. Ellis, CRWAD, Dept. of MIP, Colorado State University,
Fort Collins, CO 80523–1682.
Fax (confidential): 970–204–6684
MasterCard,
VISA, American Express, and Discover Credit cards are accepted. Credit
Card information below .
*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.
Meeting Registration Schedule
Presenters and attendees will be required to wear their CRWAD
name badge for admittance to the meeting rooms and poster sessions.
Presenters will be required to wear their CRWAD name badge during
their presentations.
Place your hotel sleeping room reservation at the Chicago Marriott (Toll–Free: 1–800–266–9432; or 506–474–2009 for international calls), by asking for the CRWAD group rate. Make your reservations at the Hotel by November 9.
For those who need a US Visa in order to attend the CRWAD meeting please start your application process early.
Proceedings: If you want to purchase a 2012 Proceedings please contact us. The on–line abstracts (searchable and printable) are accessible from the Meeting Planner and Itinerary Builder.
If you would like to present at the Annual CRWAD Meeting or would like an invitation to the meeting please contact Dr. Ellis.
CREDIT CARD INFORMATION:
If you would like to make payment by credit
card please complete the following information and Fax (970–204–6684) to Dr Ellis.
Only MasterCard, VISA, American Express, and Discover
credit cards are accepted.
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 Code _______________
Type of credit card (VISA, MasterCard, American Express, or Discover)
_______________
Signature ________________________________________________
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 970–491–5740."