IACLEA 54th Annual Conference & Exposition

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Delegate Registration Form
IACLEA 54th Annual Conference & Exposition
June 15 - June 19, 2012 • Reno, Nevada, USA
2-Year Institution
4-Year Institution
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Name
Title
Institution
Address
City State/Province Zip/Postal Code Country
Business Telephone
Fax
Email
Nickname for Badge
Spouse/Guest Name for Badge
*To order guest tickets, go to next page.
Children’s Names for Badges
Name
Name
Name
Age
Age
Age
Please indicate the events you will be attending:
Sunday - Lunch with Corporate Partners (Delegates only. There is no fee for this event, but registration is required.)
Sunday - Tour of Univ. of Nevada Reno Campus Public Safety Dept. – This is only open to Canadian & International Delegates.
Registration is free but required.
Emergency Contact
Phone
Special Needs (please list)
The registration fee includes admittance into scheduled workshops, general sessions, and the exhibit hall; coffee breaks and other
food and beverage events including Opening Reception and Lunch in the Exhibit Hall, Host Event, President’s Reception and Closing
Reception. Lunch with corporate sponsors is also included for delegates, but registration for the event is required.
Tour of Univ. of Nevada Reno Campus Public Safety Dept. is for Canadian & International Delegates only. Registration is free but
required.
REGISTRATION FEES:
(Check all appropriate boxes) Through April 30 After April 30
IACLEA Member Institution Delegate — 1st Attendee $495 $545
IACLEA Member Delegate — 2nd Attendee or More* $395 $445
Retired/Honorary Members $335 $350
Non-Member Institution — 1st Attendee $570 $620
Non-Member — 2nd Attendee or More $520 $570
* Must be an employee of a Member Institution
Grand Total — (U.S. Funds Only): $_______ $_______
METHOD OF PAYMENT: (Please check appropriate boxes)
Check enclosed made payable to: IACLEA Annual Conference
Purchase Order #___________________ (Fed. I.D. #58-1410882)
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Card #
Exp. Date
Signature
Date
IF NOT PAYING ONLINE, SEND REGISTRATION FORM
AND PAYMENT TO:
IACLEA Annual Conference
342 North Main Street
West Hartford, CT 06117-2507
Fax: 860-586-7550