Personal Information
|
| Title * |
___ Dr. ___ Mr. ___ Mrs. ___ Ms. ___ Professor
|
| First Name * |
_______________________________ |
| Last Name * |
_______________________________ |
| Institution |
_______________________________ |
| Department |
_______________________________ |
| Address 1 * |
_______________________________ |
| Address 2 |
_______________________________ |
| City * |
_______________________________ |
| State * |
_______________________________ |
| Zip Code * |
_____________ |
| Telephone * |
________________ [Include Area Code] |
| Fax |
________________ [Include Area Code] |
| Email * |
_______________________________ |
Registration Information
|
| Is your Institution a current member of CCIE? * |
___ | My Institution is a current member of CCIE.
|
| ___ | My Institution is not, please send me information on joining CCIE.
|
| ___ | I am a student and qualify for the student rate.
|
| |
| Package Choice * |
___ | Spring Conference
1 Day only. | $120.00
($150 non member)
($50.00 student) |
| ___ | Golf Tournament and Spring Conference
1 Day only. | $245.00
($275.00 non member)
($140.00 student) |
| ___ | Spring Conference
all 3 days. | $165.00
($185 non member)
($115.00 student) |
| ___ | Golf Tournament and Spring Conference all 3 days. | $290.00
($310.00 non member)
($205.00 student) |
| |
| Choose day: |
If you choose the 1 Day package, which day will you attend?
___ Thursday
___ Friday
___ Saturday
|
| |
Payment Information
|
| |
| Name as appears on Credit Card * |
_______________________________
|
| Enter Credit Card Number * |
_______________________________ |
| Choose Card Type * |
___ Mastercard ___VISA |
| Expiration Date * |
Mo: _________
|
Yr: ______
|
