National Conference Cancellation & Change Form: Add

Request Type:

For Cancellations, please complete the top portion of this form. For Change of Attendees, please complete the second portion of this form.

Cancellation

Full Name of Registrant to be Canceled:

Please include first and last name of the registered person at your institution or organization.

Cancellation Fees:

Cancellation Fee Schedule:
- $50 (Through Friday, May 1)
- $75 (May 2 to May 22)
- $100 (May 23 to May 29)
- $0 refund on May 30 or later

Reason for Cancellation:

Pre-Payment Method:

Institution/Organization:

If pre-payment was made by check, refund check should be payable to:

Mailing Address 1:

Mailing Address 2:

City:

State:

Zip Code:

Office Phone (Direct):

Email Address:

If paid by credit card, please provide the last four digits of the credit card used to make the original credit card payment:

Credit Card Type:

Expiration Date:

mm/yy

Name as it Appears on Card:

Change of Attendee|<a id="change"></a>

Full Name of Registrant to be Canceled:

Please include first and last name of the registered person at your institution or organization.

Institution/Organization:

Phone Number:

Email Address:

Full Name of New Attendee:

Please include first & last name.

Is this your first conference?:

Title:

Institution/Organization:

Address:

Address 2:

City:

State:

Zip Code:

Phone Number:

Email Address:

Confirmation Email Address:

Please provide an email address to receive your confirmation notification.