ONLINE REGISTRATION FORM

Personal Information:

Name:

Email Address:

Company/Institute: Dept:

Address:

City: Province/State: Country:

Phone: Fax:

Early Registration* Costs: GST Number R 12263 3654

Full 2 day registration $200.00 + 7% GST ($14.00) = $214.00 Can

Graduate Students $ 50.00 + 7% GST ($ 3.50) = $ 53.50 Can

University:

Late Registration* Costs (after February 1, 2005): GST Number R 12263 3654

Full 2 day registration $250.00 + 7% GST ($17.50) = $267.50 Can

Graduate Students $100.00 + 7% GST ($ 7.00) = $107.00 Can

University:

*Registration includes 2 Continental Breakfasts, 2 Lunches, and Dinner on Thursday, March 17, 2005.

Do You Intend to Submit a Poster Yes No

Do You Intend To Enter The Student Poster Competition Yes No

Payment must accompany this registration; or, if registering online, must be mailed along with a copy of your registration within one week of registration. Applications and payments should be received no later than February 28, 2005. Space is limited and will be filled on a first come, first serve basis. Please make cheque or money order payable to the Inoculant Forum and mail to the address below. Receipts will be included in the Forum registration package.

Cancellations received on or before January 31, 2005 will receive a full refund if requested.

Meals:

I will be attending Day One Evening DINNER: Yes No

SPECIAL FOOD REQUIREMENTS: Vegetarian No Fish No Pork

Other: