57th Annual Institute on Addiction Studies Online Registration Form July 10th - 14th, 2016 Please fill out all areas then click on the submit button at bottom to send or print out to mail or fax to: Institute on Addiction Studies, BOX 322, Virgil, ON L0S 1T0 Please call 1-866-278-3568 if you require further information or instructions Name: Title: Organization: Address: Home Work City: Province/State: Postal/Zip: Telephone: E-mail: Addiction Studies Forum Inc. will NOT be responsible for costs incurred for early arrivals. If a reservation is required for those arriving SATURDAY EVENING, a $150.00 fee will be added to your total. Please indicate here if you require Saturday evening accommodation > > > > Saturday Evening Accommodation $150.00 Please indicate any dietary restrictions: Please indicate your 1st & 2nd choice for courses Check this box if you have mobility issues requiring wheelchair access Sub Total . . . . Monday 1:30 p.m. - 4:30 p.m. Sunday 1:30 p.m. - 4:30 Accommodation Sub Total . . . . p.m. 1st choice 2nd choice Saturday Evening Sub Total. . . . Monday 9:00 a.m. - 4:30 p.m. GRAND TOTAL . . . . Monday 9:00 a.m. - 12:00 Payment Method Card p.m. Number p.m. Tuesday 9:00 a.m. - 12:00 Expiry Date: Month Year Tuesday 1:30 p.m. - 4:30 (Name as shown exactly on card) p.m. Cheque (make payable to Studies Forum Inc.”) “Addiction Wednesday 9:00 a.m. - 4:30 Credit Card payments also accepted by phone p.m. Wednesday 9:00 a.m. - 12:00 Print out to FAX, mail or for your records p.m. NOTE: Keynote and Plenary session(s) is included in full tuition fee otherwise a $90.00 tuition applies for each address. Wednesday 1:30 p.m. - 4:30 p.m. > > > KEYNOTE address Sunday 7:00 p.m. Check here if attending REGISTRATION POLICIES: PLENARY address Thursday 9:00 a.m. Check here if attending > > >
57th Annual Institute on Addiction Studies Online Registration Form July 10th - 14th, 2016 Please fill out all areas then click on the submit button at bottom to send or print out to mail or fax to: Institute on Addiction Studies, BOX 322, Virgil, ON L0S 1T0 Please call 1-866-278-3568 if you require further information or instructions Name: Title: Organization: Address: Home Work City: Province/State: Postal/Zip: Telephone: E-mail: Addiction Studies Forum Inc. will NOT be responsible for costs incurred for early arrivals. If a reservation is required for those arriving SATURDAY EVENING, a $150.00 fee will be added to your total. Please indicate here if you require Saturday evening accommodation > > > > Saturday Evening Accommodation $150.00 Please indicate any dietary restrictions: Please indicate your 1st & 2nd choice for courses Check this box if you have mobility issues requiring wheelchair access Sunday 1:30 p.m. - 4:30 p.m. Monday 9:00 a.m. - 4:30 p.m. Monday 9:00 a.m. - 12:00 p.m. Monday 1:30 p.m. - 4:30 p.m. 1st choice 2nd choice Sub Total . . . . Accommodation Sub Total . . . . Saturday Evening Sub Total. . . . GRAND TOTAL . . . . Payment Method Card Number Tuesday 9:00 a.m. - 12:00 p.m. Expiry Date: Month Year Tuesday 1:30 p.m. - 4:30 p.m. (Name as shown exactly on card) Cheque (make payable to “Addiction Studies Forum Inc.”) Wednesday 9:00 a.m. - 4:30 p.m. Credit Card payments also accepted by phone Wednesday 9:00 a.m. - 12:00 p.m. Print out to FAX, mail or for your records Wednesday 1:30 p.m. - 4:30 p.m. KEYNOTE address Sunday 7:00 p.m. Check here if attending > > > PLENARY address Thursday 9:00 a.m. Check here if attending > > > NOTE: Keynote and Plenary session(s) is included in full tuition fee otherwise a $90.00 tuition applies for each address. REGISTRATION POLICIES:
2016_57th_reg.docx