2007 Registration

To register, please fill out the information below. You can pay on-line using a credit card.. Alternatively, you can print a PDF document and mail/fax it to the Academy. Click here for the form to return via fax or mail

Registration: Panama 2006

Title (Dr/Mr/Ms/other):

Your name: (Required)

Your email address: (Required)

Telephone number: (Required)

Your fax number:

Position:

Employer:

Address:

City, State:

Postal code: Country:

Fulbright Country & Year:

Discipline:

Name of spouse/partner:

(Additional fee for a spouse/partner is $200)

PARTICIPATION:

Are you interested in being a speaker, exhibitor, sponsor or participant in the poster session?

Interested in being an exhibitor/sponsor: (Yes/no and Comments)

Speaker / Poster Title:

(Note: After you have completed this page, please go to the Abstract submission page to submit the full text of your abstract.)

REGISTRATION & PAYMENT:

How much is your registration? - how much are you paying?

(see below for registration costs)

How are you submitting payment?

(mailing check, faxing credit card information, submitting payment via internet - Paypal.com, etc)

IMPORTANT: If paying by credit card, please indicate if it is a personal or a business credit card !

How did you hear about the conference?:

(internet, alumni group, mailing, colleague, etc.)

Click the box below to submit the above information to the Academy.

If you wish to pay via internet, click on the box below to submit your registration and then return to this page and click on the bottom of the page to enter your credit card information through Paypal's secure internet payment program.

PAYMENT INFORMATION

Registration options:

q # __ @ $400 Regular registration (includes one year individual membership)

q # __ @ $350 Discount for members

q # __ @ $200 Discounted second registration - spouse/partner

q # __ @ $300 Discount for groups - three or more registrations

q # __ @ $300 Reduced rate for people from low & middle income countries

q # __ @ $250 Reduced rate - group of 3+ from low & middle income countries

q # __ @ Free for Exhibitors - exhibitor rate is $500 for non-profit members

q # __ @ Free for Exhibitors - exhibitor rate is $1,000 for government/corporate members

q # __ @ Free for Sponsors - call for information on sponsorship or click here.

o Special Rate For Panamanians:

q # __ @ $160 (does not include the closing program at the Gamboa).

q # __ @ $ 75 (one day only - please specify the day).

o Regular individual membership: q $ 60

o Discounted individual membership: q $ 15

o Institutional membership - varies - click here for rates.

o Donation to support participation by others q $ __________

* Low & mid-income discount is available to (1) Students, (2) Retirees, and (3) individuals living in low- & middle-income countries. This rate includes a two-year membership in the Fulbright Academy of Science & Technology.

* Greater discounts may be awarded on a case-by-case basis. If a greater discount is necessary for you to attend the conference, please send a message to ehoward@FulbrightAcademy.org.

Click on the box to submit a credit card payment using Paypal.com.
IMPORTANT: If paying by credit card, please indicate if it is a personal or a business credit card !

Alternatively, you can fax your credit card information or mail in a check (payable to a US bank). If you use one of these options, please print this page or use the printer-friendly PDF file of this registration form.

o Check enclosed (US$ or Balboa, drawn on a US or Panamanian Bank)

o Credit card (MC/Visa): ___________________________

Exp. date: ____ / _____

Name on card: _______________________

Send completed form and payment to:

Fulbright Academy of Science & Technology

PO Box CC-284, Cape Elizabeth, ME 04106-0284 USA

Fax: 1.815.846-1756

Note: The Balboa is the official currency, but US currency is used in Panama. US$ 1 = 1 Balboa.

Cancellation and other Policies:

o Those who cancel their conference registration on or before January 15 will be eligible for a full refund. Those who cancel on or before February 9 will be eligible for a refund minus a US$75 administrative fee. No refunds will be issued for cancellations received after that date.

o All registration cancellation requests must be submitted in writing to the Fulbright Academy.

o Please note that the hotels will have their own cancellation policy for your accommodations - contact your hotel for information.

o Also note that FAST may be collecting video footage, photographs and other material during the conference for use in a documentary and/or for other outreach efforts. See the main conference page for details.

o Your participation in the 2007 Fulbrighter Conference may involve travel from the hotel to off-site locations, and you may be exposed to a variety of hazards and risks, foreseen and unforeseen. By registering for the conference, you agree to waive, discharge claims and release from liability the Fulbright Academy, Inc., its officers, directors, employees, agents and leaders from any and all liability on account of, or in any way resulting from injuries or damages. By registering for the conference, you understand and intend that this assumption of risk and release is binding upon your heirs, executors, administrators and assigns, and includes any minors accompanying you.