Farms at Work Delegate Registration Form

Farms at Work Delegate Registration Form

STEP 1: Personal Details (Please print clearly. Enter single registrant or administrator of a group. )

☐ Prof. ☐ Dr. ☐ Mr. ☐ Mrs. ☐ Ms. (please check one)

First Name:Click or tap here to enter text. Last Name:Click or tap here to enter text.

Title: Click or tap here to enter text. Company:Click or tap here to enter text.

Address:Click or tap here to enter text.

City: Click or tap here to enter text. Prov/State: Click or tap here to enter text.

Country: Click or tap here to enter text. Postal Code/Zip: Click or tap here to enter text.

Phone: Click or tap here to enter text. Fax:Click or tap here to enter text.

Email:Click or tap here to enter text.

Registration fee includes the Tuesday lunch and afternoon coffee break and the afternoon session.

STEP 2: Registration

Producer Registration: $147.50 plus HST @13% = $166.70 $Click or tap here to enter text.

Grand Total $ Click or tap here to enter text.

All payments must be made in Canadian funds. Registration will not be processed or acknowledgements sent until payment is received.

GST# 893865915

STEP 3: Method of Payment

Please choose one form of payment, tick “x” where applicable and complete the details below.

Pay by Credit Card (please check one)

☐VISA ☐MasterCard

Credit Card number: ______

Expiry Date (MM/YY): ______

Name as it appears on the front of the card: ______

CCV Code:______

☐ I authorize the use of my credit card

(By agreeing, you authorize the use of your credit card. Your credit card statement will read “Iris Meck Communications Inc.”)

Cancellation Policy

No refunds will be processed, however, you can substitute attendees by contacting Iris Meck Communications Inc. by phone at: 403-686-8407, fax: 403-255-4592 or by email at:

Dietary Restrictions

Please advise of any food restrictions or dietary requirements that need to be met:

______

Registration Deadline: only the first 15 registrants will be accepted at this price. All other registration can be made at the full registration price for the full conference.

Registration will close on Thursday September 29, 2016 at 4:00 pm and will resume on-site on Monday October 3, 2016 at 12.30 pm.

The conference will be recorded and photographed at the discretion of Iris Meck Communications Inc. Your registration and attendance at the event signifies your permission to utilize your image and/or likeness or words spoken or written about the Advancing Women Conference in printed and online reporting of the event in future promotions for perpetuity. No limitations or restrictions apply.