2004 Registration

All participants must register & pay the appropriate fees; meals are NOT included.

Please check one:
__ Advance Registration $65
__ Presenter $75
__ Student Presenter $65
__ Attendee/non-presenter $25

Method of Payment:
___ Cash
___ Check (payable to BGSU)
___ Credit Card (circle card type & complete the necessary information below)

Visa       MasterCard       Discover Card

#: _________________________________________________

Expiration Date: ___________________________________________

Print Name: ______________________________________________

Signature: _______________________________________________

 

Please complete the following information:

Name: __________________________________________________________

Social Security #: __________________________________________________

Institution: ________________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

Email: ___________________________________________________________

Phone/Fax: _______________________________________________________

 

Print this form and fax it to Continuing Education Office at (419)372-8667 or call them toll-free at 1-(877)-650-8165 to register before the conference. On-site registration is also possible.