Event Registration
(mm/dd/yyyy)
(mm/dd/yyyy)
Please provide your:
Name
Company
Address
City
State/Province
Country
Phone
Fax
E-mail
How did you learn about the upcoming Event?
Direct Mailing
Related Event 1
Related Event 2
From a friend/colleague
Other
Would you like the informational materials about the Event to be mailed to you in advance?
Yes
No
Other
Would you like us to book a hotel room for you?
Yes
No
Other
Please tell us how long you are going to stay
Arrival
Departure
Once your registration is complete, the hotel reservations will be made for you.
Please select the hotel room type you would prefer
Single
Double
Single/Nonsmoking
Double/Nonsmoking
Other
Do you need a special diet? Please comment if necessary
Yes
No
Comments
Please select your preferred method of payment:
On-line secure credit card
Credit card via fax
Cheque
Other
Please provide any additional comments
