Personal Information :
First Name :
Last Name :
Title :
Institution / Organization :
Phone : - -
Fax : - -
Email :
Billing Address :
Address :
Address1 :
City :
State :
Zipcode :
Registration Options :
Early
Before April 15th
Regular
After April 15th
Member
$125
$150
Student
$ 63
$ 75
Pre-Conference Workshop
(Wednesday Morning)
$ 30
$ 30
Total Due :
For planning purposes, I intend to attend the following : (Included in registration fees)
Dinner/Cocktails on 15th
Noon Lunch on 16th
Special Event Dinner
     
Payment Options (Must be received by March 15th for early registration)
(Check or Purchase Order must be made payable to - The University of Texas-Pan American)
PO #
Check
Visa MasterCard Discover

Card Number Exp Date / Card Holders Name

Signature
(I authorize payment for the registration for the amount indicated above)
 
Special Requests : (You will be contacted individually)
Bus Service to & from hotel required
Special Dietary Requests
Accomodation for a Disability
Any additional Requests:


Mail To:
ITDE Conference The University of Texas Pan American
Payments and Collections
1201 W University Dr., SS 115
Edinburg, TX 78539

Fax To :
956-384-5064

Phone Payments:
956-381-2715