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Registration Form
FUNDAMENTAL & APPLIED BIOELECTRICS
An International Scientific Workshop July 23-27 2012
Title (Ms., Mr., Dr., Prof .):_____
First Name___________________________ Last Name ______________________________________
(Surname, Family Name)
Affiliation _________________________ _________________
Address ________________________________________________________________________________________
City_________________________________________State/Province_______________________________
Postal Zone/Zip Code______________________________ Country__________________________________________
Telephone________________________________________ Fax________________________________
(Please include country code and area code for both Telephone and Fax.)
E-mail (TYPE clearly):____ _____________________________________________
(E-mail address is vital, since we are moving toward electronic information dissemination.)
_____I do NOT want my e-mail address to appear on the participant list.
Name as you would like it to appear on your badge __________________________________________
Please indicate if you will be attending the following functions:
Reception in Frank Reidy Research Center for Bioelectrics (Sunday Evening, 07/22/12):
YES___ ____ NO________
Social afternoon (wednesday, 07/25/12) :
YES_____ NO_______
Registration Fee inclusive of workshop and social functions (Payment Must Accompany Registration Form):
$350.00/person
Registration Payment:
If Paying by Credit Card Please Provide the Following Information:
Cardholder’s Name [as it appear on the card]:__ __________________________________
Credit Card Number:__ ____________________________________________________
Type of Credit Card Circle one): MasterCard or Visa (the only credit cards accepted)
Security Code on the Credit Card (located on the back of the card): ________________________
Credit Card Billing Address:_ __________________________________________________________
Telephone Number Associated with the Credit Card:_ _______________________________
Expiration Date on the Credit Card: _____________________
Month (2 digits) Year (4 digits)
This information along with the Registration Form can be mailed to Barbara Carroll at 4211 Monarch Way, Suite 300, Norfolk, Virginia 23508 USA or FAXed to her at +1-757-451-1010 or Scanned and e-mailed to bcarroll@odu.edu.
If paying by check:
Please make the check payable to “ODURF” AND mail the Registration Form and check to: Barbara Carroll at 4211 Monarch Way, Suite 300, Norfolk, Virginia 23508 USA.
Important Facts:
- Payment MUST accompany registration form. Registration by fax is allowed ONLY if using a credit card. Fax registration to: +1(757) 451-1010.
- Payment must be in U. S. Dollars and made by check, money order, Mastercard or Visa, We cannot accept any credit cards other than the ones specified.
- Please remit check payable to: Old Dominion University Research Foundation.
- We can NOT accept electronic/bank transfers.
- Confirmation and receipt will be sent via e-mail to the e-mail address provided on the registration form. Each attendee will be provided with a booklet of abstracts with his/her symposium materials.
- We cannot accept any credit card other than Mastercard or Visa.
FOR OFFICE USE ONLY
Check #_______________
Amount US$___________
Date Rec'd_____________
Invoice #_______________
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