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  • Registration Form for 23rd Annual Meeting of OHBM

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    tomasgoucha
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    This document is a registration form for the 23rd Annual Meeting of the Organization for Human Brain Mapping taking place in Vancouver, Canada. It lists the various registration options and associated fees, including full conference registration, one day registration, guest tickets, and educational course fees for members, non-members, students, and enhanced registrations. It also requests payment information and details about paying via credit card or wire transfer.

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    OHBM 2017

    Original Title

    Registration

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    This document is a registration form for the 23rd Annual Meeting of the Organization for Human Brain Mapping taking place in Vancouver, Canada. It lists the various registration options and associated fees, including full conference registration, one day registration, guest tickets, and educational course fees for members, non-members, students, and enhanced registrations. It also requests payment information and details about paying via credit card or wire transfer.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    22 views1 page

    Registration Form for 23rd Annual Meeting of OHBM

    Uploaded by

    tomasgoucha
    This document is a registration form for the 23rd Annual Meeting of the Organization for Human Brain Mapping taking place in Vancouver, Canada. It lists the various registration options and associated fees, including full conference registration, one day registration, guest tickets, and educational course fees for members, non-members, students, and enhanced registrations. It also requests payment information and details about paying via credit card or wire transfer.

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    © All Rights Reserved
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    REGISTRATION FORM EARLY (closes 3/30/17) Please Note:

    All prices are listed in


    23rd Annual Meeting of the Organization for Human Brain Mapping
    USD
    Vancouver, Canada

    Last Name________________________________________ First Name____________________________ MI ________ Degree_______

    Company_____________________________________________________________________________________________________________

    Address______________________________________________________________________________________________________________

    City________________________________________ State ______________ Country _________________________ Zip ________________

    Phone________________________________________________Email ___________________________________________________________

    Full Conference Registration One Day Registration GUEST Tickets

    Member $235 Your registration includes a ticket to the


    Member $595
    Welcome Reception and Club Night.
    Member Enhanced* $695 Member Enhanced* $335 Use the selection below ONLY if you
    would like to bring a guest.
    Non Member $745 Non Member $360
    Student Member $235 Student Member $140 Welcome Reception Guest
    Student Member Enhanced* $285 Student Member Enhanced* $190 @ $50 Each _____
    Club Night Guest
    Student Non-Member $375 Student Non-Member $200 @ $50 Each _____

    *enhanced registration includes 2017 OHBM membership

    Educational Courses, June 26, 2016

    Those attending Educational Courses are required to pay the rates as listed below. Both full and day courses will be offered
    and attendees are allowed to move between courses as they desire.

    Member $125 Non-Member $175 Student Member $50 Student Non-Member $75

    Payment Information

    Total Amount Due = $________________

    Mastercard AMEX Visa Discover

    Credit Card Number__________________________________________ Exp Date C V V Code________

    Name on Card ______________________________________________________________

    I would like to pay by wire transfer: Name of bank________________________________________________

    Upon receipt of this complete registration form, you will receive an official invoice with the wire transfer information.

    Organization for Human Brain Mapping / 5841 Cedar Lake Road, Suite 204 / Minneapolis, MN 55416
    Phone: (952) 646-2025 / Fax: (952) 545-6073
    Web: www.humanbrainmapping.org / Email: info@humanbrainmapping.org

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