ATTENDEE REGISTRATION FORM: BICoB-2010
Please complete this form (TYPE or PRINT)
and return by
JANUARY 15, 2010 for early registration rate.
FIRST Name: _________________MI
_____ LAST Name: ___________________________________________
Title ( Dr / Mr / Mrs / Ms ): _________Position:
________________ Organization:
______________________
Address:
___________________________________________________________________________________
City:
___________ State/Province:
____________ Zip/Postal Code _____________ Country:
____________
Telephone: ___________________________ Fax:
______________________________________________
E-mail: ______________________________ List your areas of interest:
_____________________________
PLEASE NOTE: To
become a NEW ISCA member at this time, or if you would like
to renew your ISCA Membership for 2010, please check both the ISCA MEMBER RATE *
and
the 2010 ISCA MEMBERSHIP** boxes below when you register.
| EARLY REGISTRATION FEE (RECEIVED BY JANUARY 15 , 2010) | ||
| ISCA MEMBER | $450.00 | _________ |
| NON-MEMBER | $550.00 | _________ |
| 2010 ISCA MEMBERSHIP | $100.00 | _________ |
| * STUDENT (includes ISCA student Membership) | $ 25.00 | _________ |
| * The luncheon banquet and Conference Proceedings are not included with student registration but may be purchased separately. | ||
| REGISTRATION FEE (RECEIVED AFTER JANUARY 15, 2010) | ||
| ISCA MEMBER | $500.00 | _________ |
| NON-MEMBER | $600.00 | _________ |
| 2010 ISCA MEMBERSHIP | $100.00 | _________ |
| * STUDENT (includes ISCA student Membership) | $ 25.00 | _________ |
| ADDITIONAL FEES: | ||
| Additional Luncheon Ticket: | $ 50.00 / each | _________ |
| 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 # __________________________ ZIP CODE of
Billing
Address _________________
_________________________________________________________
(Signature
REQUIRED)
(PLEASE INDICATE YOUR CHOICE BELOW)
I plan to attend the complimentary
LUNCHEON on March 25, 2010
¨Yes
¨
No
Special dietary requirements: __________________________________
Note: Sleeping Rooms are blocked for our group at the Sheraton Waikiki Hotel -- see Hotel Information.
REGISTRATION FEES ARE NON-REFUNDABLE.
FAX (919) 467-3430 or mail this completed form along with the Registration Fee to:
ISCA
ATTN: BICoB-2010 Registrar
975 Walnut Street, Suite 132
Cary, NC 27511-4216
EIN NO: 56-1799522
If you have any registration questions, please contact us: Telephone: (919) 467-5559; Fax: (919) 467-3430; Email: isca@ipass.net, mary.ann.sullivan2@gmail.com
ISCA EIN Number: 56-1799522