2016 ISM CONFERENCE REGISTRATION

ISSSEEM CONFERENCE REGISTRATION
SCIENCE SYMPOSIUM: September 21

MAIN CONFERENCE: September 22 -24

POST CONFERENCE WORKSHOPS: September 26 - 28
Full Name *
First Name Middle Name Last Name

Address *

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

E-mail *
Phone Number *
- Area Code Phone Number
Dietary Needs

Vegetarian Meals Non-Vegetarian Meals Gluten-Free Meals Vegetarian, Gluten-Free Meals

Conference Plans (Choose One Meal Plan). *

PLAN #1 Conference Only, No Meals. $ 450.00
PLAN #2 Conference + Wednesday Light Supper. $ 464.00
PLAN #3 Conference + Lunch & Dinner Through Saturday Lunch. $ 583.00
PLAN #4 Conf.+Wed Light Supper+Lunch & Dinner Thur-Sat Lunch. $ 597.00
Add Optional Post-Conference Workshops Mon-Wed (Concurrent). $ 150.00

Choose One

Total: $ 0.00

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

ISSSEEM Conference Refund Policy for 2016:

Through August 22 - Full Refund, less $50 administrative fee;

From August 23 through September 12 - 50% Refund, less $50 administrative fee; and

After September 12 - No Refund.
Check, if Yes

I require Disability Access for stairs at the Conference. I plan to attend all or part of the Wed. Science Symposium. I have previously attended an ISSSEEM Conference.
How did you hear about the Conference? *

Email Promotion Post Card Evolving Magazine Council Grove Conference Friend(s) Internet Other
Date *
- Month - Day Year
Enter the message as it's shown *
If you are outside the U.S., or have a problem working with this form, please call Marilyn at 888-272-6109x3 (Monday-Thursday, 9 am - 5 pm Central Time).
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ISSSEEM CONFERENCE REGISTRATION

If you are outside the U.S., or have a problem working with this form, please call Marilyn at 888-272-6109x3 (Monday-Thursday, 9 am - 5 pm Central Time).