REGISTRATION FORM
Fax to: 626-466-4433
Mail: GTCbio, 635 W. Foothill Blvd, Monrovia, CA 91016

Use this form to register u...
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7th Diabetes Drug Discovery and Development Conference (April 23 - 25, 2014, Cambridge, MA)

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7th Diabetes Drug Discovery and Development Conference (April 23 - 25, 2014, Cambridge, MA)

  1. 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 _________________________________________ Organization _________ SAME AS ATTENDEE #1 __________ Organization _________ SAME AS ATTENDEE #1 _________ Organization _________________________________________ Mailing Address _________________________________________ Mailing Address ________________________________________ Mailing Address _________________________________________ City, State & Zip Code _________________________________________ City, State & Zip Code ________________________________________ City, State & Zip Code ___________________ Phone ___________________ Phone ___________________ Phone ____________________ Fax _________________________________________ Email Address: ____________________ Fax _________________________________________ Email Address: ___________________ Fax ________________________________________ Email Address: NAME OF CONFERENCE ATTENDING: _______________________________________________________________________________ PRICING OPTIONS: Rate Please include the registration rate listed on the GTCbio website Commercial _____________________  20% early registration discount for registering 60 days prior to the conference Acad./Gov. _____________________  10% early registration discount for registering 30 days prior to the conference Student _____________________  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 ABA Routing #: 121-000-358, Account #: 0230604059 Swift Code: Bofaus6s **BANK TRANSFER REQUIREMENTS: When submitting a bank transfer, please add the name of the attendee on the transfer.

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