Form

Registration Form

2012 MACTE/IAME Conference
Full Name*
First Name Last Name
Name to Appear on Badge
Institution/Program*

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
E-mail*

Registration Fee

Single Participant $300.00 USD
Multiple Participants $250.00 USD

Number of Participants

Total: $0.00 USD

Credit Card
First Name	Last Name
- Credit Card Number Security Code
/ Expiration Month Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

At this time we can only accept Visa, Mastercard and Discover. We do not accept American Express.
For multiple participants, please click next.
Note: In the event of registration cancellation, fees paid in advance are refundable less a $50 service charge, provided that written notice is received by MACTE by November 1, 2012. There will be no refunds for cancellations received after November 1, 2012. There will be no refunds for no-shows. All refunds will be processed after the conclusion of the conference.

Full Name
First Name Last Name
Name to Appear on Badge
Institution/Program

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
E-mail
Click next to add another participant. If you are finished please press submit.

Full Name
First Name Last Name
Name to Appear on Badge
Institution/Program

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
E-mail
Click next to add another participant. If you are finished please press submit.

Full Name
First Name Last Name
Name to Appear on Badge
Institution/Program

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
E-mail
Click next to add another participant. If you are finished please press submit.

Full Name
First Name Last Name
Name to Appear on Badge
Institution/Program

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
E-mail
Click next to add another participant. If you are finished please press submit.

Full Name
First Name Last Name
Name to Appear on Badge
Institution/Program

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
E-mail
Should be Empty: