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.

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