4th Diabetes Partnering and Deal-Making Conference (April 23 - 25, 2014, Cambridge, MA)
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4th Diabetes Partnering and Deal-Making Conference (April 23 - 25, 2014, Cambridge, MA)

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4th Diabetes Partnering and Deal-Making Conference (April 23 - 25, 2014, Cambridge, MA) Document Transcript

  • 1. REGISTRATION FORM Fax to: 626-466-4433 Mail: GTCbio, 635 W. Foothill Blvd, Monrovia, CA 91016 Use this form to register up to 3 attendees – Please TYPE or PRINT your responses clearly Attendee #1 Attendee #2 Attendee #3 _________________________________________ _________________________________________ ________________________________________ Name Name Name _________________________________________ _________________________________________ ________________________________________ Job Title Job Title Job Title _________________________________________ _________________________________________ ________________________________________ Department Department Department _________________________________________ _________ SAME AS ATTENDEE #1 __________ _________ SAME AS ATTENDEE #1 _________ Organization Organization Organization _________________________________________ _________________________________________ ________________________________________ Mailing Address Mailing Address Mailing Address _________________________________________ _________________________________________ ________________________________________ City, State & Zip Code City, State & Zip Code City, State & Zip Code ___________________ ____________________ ___________________ ____________________ ___________________ ___________________ Phone Fax Phone Fax Phone Fax _________________________________________ _________________________________________ ________________________________________ Email Address: Email Address: Email Address: NAME OF CONFERENCE ATTENDING: _______________________________________________________________________________ PRICING OPTIONS: Rate Commercial _____________________ Acad./Gov. _____________________ Student _____________________ Please include the registration rate listed on the GTCbio website  20% early registration discount for registering 60 days prior to the conference  10% early registration discount for registering 30 days prior to the conference  Register 2, the 3rd person Goes Free. Early Registration Discounts DO NOT apply Fax to: 626-466-4433 PAYMENT METHOD (CHECK ONE)  Check*  Bank Transfer**  Money Order  Visa  MasterCard  American Express  Discover Card #: __________________________________________________________ Exp: Date: ______________________ CSV #: ______________________ Cardholder Name: _________________________________________________ Signature: ___________________________________________________ Billing Address Street Address: _________________________________________________ City, State, Zip : ________________________________________________ HOW DID YOU HEAR ABOUT THIS CONFERENCE: ________________________________________________________________ CANCELLATIONS All cancellations will be subject to a $195 cancellation fee. In order to receive a refund, you must submit a written notice of cancellation (by letter or fax) no later than 6 weeks prior to the conference. We regret that refunds will not be issued after this date. A conference voucher will be issued for use at any future GTCbio conferences within 12 months of cancellation. If you plan on sending a substitution in your place, the substitution must be from the same organization. Please notify GTCbio of any substitutions as soon as possible so the proper preparations can be arranged. In the event of a conference cancellation, GTCbio is not liable for transportation, hotel, or other costs incurred by registrants. *Checks must be drawn on a US bank and made payable to Global Technology Community, or GTCBIO. International money orders are also acceptable. **Bank Transfer Information: Bank of America, 230 S. Myrtle Ave., Monrovia, CA 91016 **BANK TRANSFER REQUIREMENTS: When ABA Routing #: 121-000-358, Account #: 0230604059 submitting a bank transfer, please add the name of the Swift Code: Bofaus6s attendee on the transfer.