COURSE REGISTRATION for 47th ANNUAL SHORT COURSE

ADVANCES IN EMULSION POLYMERIZATION AND LATEX TECHNOLOGY

1-WEEK SHORT COURSE

June 6–10, 2016

Lehigh University

Bethlehem, Pennsylvania 18015USA

COURSE REGISTRATION FORM

Mr. / Mrs./Ms.
Name
Last Name
/
First Name
/ Initial
Title
Organization
Street Address 1
Street Address 2
City / State / Zip Code
Country / Telephone:
Fax / E-Mail Address:
Dates Attending (please specify)

ACCOMODATIONS(Please check all appropriate boxes)

University Housing (Campus Square) / (NOTE: Campus Square Suite to be shared with 2 other participants) (see next page for fees)
Hotel/ Motel Name:
(Complete section below ONLYif you want us to make reservations for you)
Date of Arrival:
Number of Nights: / Number of Persons
Credit Card Name, Number, and Expiration Date to guarantee Hotel/Motel reservations ONLY:

COURSE TUITION (INCLUDING DISCOUNTS)

Standard Course Tuition / $1,600
“Early Bird” Discount (prior to February 12, 2016) / $1,525
Multiple Participants Discount (2 or more participants from the same company) / $1,450 Each
1st Authorized EPI Liaison Member Registrant (1st participant is free; cost for 2 participant or more is $1275 each) / $0
EPI Liaison Member Registrant- 2nd participant or more @ $1275 Each / $1,275
Graduate Student / $ 800
1 Day Registration / $725
2 Day Registration / $1450

FEE FOR UNIVERSITY HOUSING

University Housing at $65/person/night / Date of Arrival:
Estimated Time of Arrival:
Roommate Request:
Date of Departure:
Number of Nights:
Housing Total Costs (= # of nights  $65/night)
University Housing Parking: $5/car/day / Arrival Date:
Departure Date:
Number of days:
Parking Total Costs (= # of days  $5/car/day)
Registration and Housing: Total Cost

PAYMENT OPTIONS

Check will be sent with a copy of this registration form / Please send an invoice to me at the address given above
Bill my credit card (see form below)
I authorize you to charge my credit card in the amount of :
Bill my: / Visa / MasterCard / American Express
Account Number: / Expiration Date:
Name on Card:

Participants may reserve a space for the Short Course by completing the form above, and either:

(1) printing it and then mailing it, along with a check payable to: Lehigh University/Emulsion Polymers Course

Ms. Debra Hartzell Nyby

Emulsion Polymers Institute

Lehigh University

111 Research Drive

Bethlehem, PA 18015-4732 USA

Telephone: (610) 758-3607 Fax: (610) 758-5880 e-mail:

OR(2) completing the form above and sending it as an e-mail attachment to Debra Hartzell Nyby at the e-mail address listed above and checking the box on the form indicating whether you will be sending a check or if you would like to be sent an invoice.

OR(3) entering the credit card information using the format described below and sending this form as an e-mail attachment to Debra Hartzell Nyby at the address listed above.

************************** IMPORTANT ****************************************

IF USING A CREDIT CARD FOR PAYMENT OF THE COURSE TUITION/HOUSING, PLEASE FAX THIS COMPLETED FORM TO: (610) 758-5880 OR CALL DEBRA HARTZELL NYBY AT (610) 758-3607 TO GIVE THE CREDIT CARD INFORMATION OVER THE PHONE TO ENSURE YOUR SECURITY.

Refund requests received before April 11, 2016 will be honored in full. After April 11, there will be a processing charge of $725 deducted for meeting cancellation and a processing charge of one night will be deducted for housing cancellations.

We would greatly appreciate it if you could check the box below indicating how you learned about this Short Course. Thank you very much for your input.

A Colleague in my company
Liaison Member
Previous Attendee
Trade Association
Emulsion Polymer Institute’s Web Site
Other (please indicate source: )