CIMPA / ITMIC ALBUQUERQUE REGIST

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CIMPA / ITMIC ALBUQUERQUE REGISTRATION FORM
NOVEMBER 13-15, 2004

GENERAL INFORMATION

You may print this form and fax or mail it to us. Your payment may be made by credit card, check or bank transfer. For online registration, please visit our registration page.
Accommodations: Accommodations (double occupancy) on November 11, 12,13, 14 are included in your registration. CIMPA will book hotel rooms on behalf of all participants. You do not need to call the hotel.
VISA TO THE USA - CIMPA will send letters of invitation to all those who need one to obtain a visa. To ensure that you will be able to get your US visa, IT IS IMPORTANT that you file your application early.

1. CONTACT INFORMATION

First Name:	____________________________________	Last Name:	____________________________________
Title:	____________________________________	Organization:	____________________________________
Street address:	____________________________________	Address (cont.):	____________________________________
City:	____________________________________	State/Province:	____________________________________
Zip/Postal code:	____________________________________	Country:	____________________________________
Telephone:	____________________________________	FAX:	____________________________________
E-mail:	____________________________________	URL, if any:	____________________________________

2. Fee - $395 (Early Bird - before September 15) $740 (after September 15)
Includes 4 nights accommodations on Nov 11,12, 13, 14 (double)
Single Supplement: add $150 for entire stay
Extra nights: $119 per night, single or double

3. QUANTITY AND FULL NAME OF COMPANION(S), if any (Companion Fee: $175 each):

Quantity: ______ (Maximum 2). Fee for non-industry spouse sharing the same room is $175.
Companion 1: ______________________________________	Companion 2: ______________________________________

4. QUANTITY AND FULL NAME OF CHILDREN, if any:

Quantity: ______ (Maximum 2). FREE REGISTRATION for children up to 16 years staying with parent in the same room:
Child 1: ______________________________________	Child 2: ______________________________________

5. TRAVEL INFORMATION

Departure City: ___________________________	Departure Country: ___________________________
Departure Date: __________________________ (mm/dd/yyyy)	Return Date: ___________________________ (mm/dd/yyyy)

6. TOURS

Select all of the tours you wish to sign up for, and indicate the number of people in your party taking the tour in the box.
Santa Fe	Calsbad Caverns

7. SPECIAL EVENT FOR DISADVANTAGED CHILDREN (Voluntary)

CIMPA invites disadvantaged children from the area to the conference site for an afternoon of fun and caring. Gifts and school supplies are distributed. Thank you for sharing! Indicate how many children you would like to sponsor for $20 each. ______

8. Certification Examination

CPPM ($195) CGMP ($195) CIMP ($195)

Application Form and Review Materials are included in the above fee 9,

9. OTHER REQUESTS, COMMENTS OR CLARIFICATION, If any

If you are a speaker. a member of a cooperating organization or if you participated in a n Early Bird promotion, please indicate here:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

11. TOTAL AMOUNT TO BE PAID: $_________________________

12. HOW TO PAY

By Check:	Please make check payable to CIMPA and mail to CIMPA, Attn: Becky Smith, 9200 Bayard Pl, Fairfax, Virginia 22032	By Bank Transfer:	Send payment to: Navy Federal Credit Union, Vienna, Virginia, ABA # 2560 7497 4, Account # 106 3918 302
By Credit Card Offline:	Call 1 703 286-2142 or enter your credit card information below and fax your registration to: 1 703 991-2292.

Credit Card Type:	Visa MasterCard American Express
Credit Card Number:	____________________________	Expiration Date:	Month __________Year ___________
Name on Credit Card: _________________________________Signature____________________________

FAX TO 1 703 991-2292

Or mail to: ITMIC Registration, Attn: Becky Smith
9200 Bayard PL Fairfax, VA 22032 USA

CANCELLATION POLICY: Full refund with $95 processing fee if cancelled by September 1
50% refund by September 15. No refund after October 1

SINGLE TRIP TRAVEL INSURANCE: For a small fee, you are protected for Trip Cancellation, Baggage, Medical, Dental, Emergency Evacuation, 24 Hour Traveler Assistance, Baggage Delay, Travel Delay, and Accidental Death Coverages. Visit http://www.insuremytrip.com to compare rates from different providers.

Connected International Meeting Professionals Association

Connected International Meeting
Professionals Association