ATTENDEE
REGISTRATION FORM: ACC-2010
September 15-17, 2010, Orlando, Florida USA
Please complete this form (TYPE or PRINT)
and return by JULY 16, 2010 for early registration rate.
FIRST Name: ___________________________ MI
_____ LAST Name: ____________________________________________________
Title (
¨ Dr. or
¨
Student)
and (¨ Mr.
¨Mrs.
¨Ms.)
Position
___________________ Organization ___________________________
Address:
_______________________________________________________________________________________________________
City:
________________ State/Province:
__________________ Zip/Postal Code __________________ Country:
__________________
Telephone: ____________________________________ Fax:
______________________________________________________
E-mail: _______________________________________________ List your areas of interest:
__________________________________
PLEASE NOTE: NON-MEMBERS who would like to
become a NEW ISCA member at this time, or if you would like
to renew your
ISCA Membership for 2010 at this time, please check both the ISCA MEMBER
RATE * and the 2010 ISCA
MEMBERSHIP** boxes below.
| EARLY REGISTRATION FEE (RECEIVED BY JULY 16, 2010) | ||
| ISCA MEMBER | $450.00 | _________ |
| NON-MEMBER | $550.00 | _________ |
| 2010 ISCA MEMBERSHIP | $100.00 | _________ |
| * STUDENT | $ 25.00 | _________ |
| (includes ISCA student Membership) | ||
| * The luncheon banquet and CD Conference Proceedings are not included with student registration but may be purchased separately. | ||
| REGISTRATION FEE (RECEIVED AFTER JULY 16, 2010) | ||
| ISCA MEMBER | $550.00 | _________ |
| NON-MEMBER | $650.00 | _________ |
| 2010 ISCA MEMBERSHIP | $100.00 | _________ |
| * STUDENT | $ 25.00 | _________ |
| (*includes ISCA student Membership) | ||
| ADDITIONAL FEES: | ||
| Additional Luncheon Ticket: | $ 50.00 / each | _________ |
| Additional ACC-2010 CD Proceedings : | ||
| ISCA member | $ 50.00 / each | _________ |
| Non-member | $ 75.00 / each | _________ |
| Proceedings (BOOK format) can be ordered online at www.proceedings.com approx. two weeks after the conference. | ||
| TOTAL: | _________ | |
METHOD OF PAYMENT:
__Check __Money Order
__Visa __MasterCard
Payment may be made by check, International money order (in U.S. dollars drawn
on a U.S. Bank made payable to ISCA), or credit card in U. S. Dollars.
Credit Card # __ __ __ __ - __ __ __ __ - __
__ __ __ - __ __ __
__
Expiration Date ________/_______
Security Number on
Back of Credit Card ______________
Print Name as it appears on Card
______________________________
Billing Street Address
No. __________________________ ZIP CODE of
Billing
Address _________________
_________________________________________________________
(Signature
REQUIRED)
(PLEASE INDICATE YOUR CHOICE BELOW)
I plan to attend the complimentary
LUNCHEON
on Sept. 16, 2010
¨Yes
¨
No
Special dietary requirements:
_________________________
Please FAX to: (919) 467-3430 or mail this completed form along with your Registration Fee to:
ISCA - ACC-2010 Conference
975 Walnut Street, Suite 132
Cary, NC 27511-4216
If you have any registration questions, please contact
Mary Ann Sullivan at: Telephone: (919) 467-5559; Fax: (919) 467-3430 or E-mail:
isca@ipass.net