Delegate Registration

*Indicates Required fields

For alternative registration method please download the registration form

Personal Information

*First Name:

*Last Name:

*E-mail:

(e.g. jdoe@itlife.ca)

Company/Employer:

Mailling Address

*Address 1:

Address 2:

*City:

*State/Province:

*ZIP Code/Postal Code:

*Country:

*Phone:

Fax:

Registration Information

Correct mailing address required for mailing CD containing conference proceedings

Full delegate rate includes daily continental breakfast, all social events and banquet ticket

	*Name to appear on Name Tag :
	CRPA - Member ($650), Early Bird Fee $625 before April 1, 2012 Advance registration closes May 18, 2012 - onsite registration fee of $700
	Non-Member ($700)
	Retiree ($300)includes all social events, daily breakfast and banquet ticket
	Student ($50)includes all scientific sessions, banquet ticket is not included
	Day Registration ($300/day) Check all days attending: evening social events & banquet not included

Monday Tuesday Wednesday

WORKSHOPS Separate from conference fee and subject to a minimum number of registrants.

Workshop #1: Radiation Safety Officer Refresher: Thurs May 31 (9-5pm) $250

Workshop #2: Portable and Fixed Gauges Radiation Safety: Wed May 30 (8:30-12) $200

Additional banquet ticket ($150 each)

Credit Card Information

*Select Credit Card:

*Credit Card Number:

*Name on Card:

*Expiration Date:

Digital Signature

Please Check*

I understand I am registring for CRPA-ACRP Conference.