11th Congress
Registration To Register please
complete all fields, print, and fax to 225-578-0276
Registration
Attn: Tina Black
225-578-0276 Fax Registration
225-578-9094 Phone Registration
If you do not receive registration
confirmation within 48 hours of submitting registration please call
the Congress Office at 225-578-9094 or
E-Mail
First Name:
Last Name:
E-Mail Address:
Affiliation:
Registration Fee:
$250.00 Early Registration (before April 29)
$350.00 Registration (after April 29)
$150.00 Student Registration
$150.00 Accompanying
Person(s)
Picnic and Durham
Bulls Ballgame:
x
$25
Billing
Information:
Name (As it appears
on Credit Card):
Credit Card Holder
Billing Address:
City:
St.:
Zip:
Phone Number:
Email Address:
Credit Card Type:
Visa
MasterCard
American Express
Discover
Credit Card Number:
Exp. Date:
Code#
*This is 3 or 4 digit number on the
back of your card after the last digits of account number
Please let this serve as an
authorization to charge my credit card in the amount of
$
for registration for the 11th International Congress on Combustion
By-Products and Their Health Effects.
Signature:
_______________________________________
By signing, I agree to this charge.
Cancellations received before
May 1, 2009 will be refunded in full less $50.00. After May 1st, no
refund will be possible.