THE AMERICAN COLLEGE OF CHIROPRACTIC CONSULTANTS
&
Council on Forensic Sciences
Conference Registration Form

To register, complete boxes A through C & total in box D

Full Conference Registration – November 7-9 Includes one (1) ticket to       Postmarked by

All meal functions                   October 25

ACCC or CFS Member                                              ƒ  $350

Join & Register (prorated for ’03-new members only)  ƒ  $420

ƒ ACCC        ƒ CFS  

  Add $100 for each org checked                                   ƒ $___

  Nonmember                                                                 ƒ $450

All registrations postmarked after August 19th, and at the door (space available) add $100

                                      Subtotal A $_______

Additional Meal Tickets                    C

Friday Breakfast                        ƒ $12

Saturday Breakfast                     ƒ $12

Sunday Breakfast                        ƒ $12

   D

TOTAL AMOUNT $     ________________                         

3         easy ways

to register

         Mail

           Dr. David Cox

           2741 Ridge Rd

           Lansing, IL 60438

            Phone

            708-895-3141

            Mon-Fri, 9 am-5pm

             (CDT – credit card

             Payment only)

ACCC /CFS Examinee Registration          B

   (reduced rate for (examinees)  

      Includes one (1) ticket to all  meal functions

ACCC or CFS Examinee                    ƒ  $150

All registrations postmarked after August 19th, and at the door (space available), add $100

                                       Subtotal B $________

Special Requests

  ƒ I will need a vegetarian meal

 
 ƒ I will be using a wheelchair at conference

  (info needed to project space accommodation

    for meeting rooms and other functions)

             Fax

              708-895-2268

·          If you fax this form, please do not mail original

·          Fax and phone orders accepted only with credit card payment

Payment must accompany registration

Payment (must accompany registration form)

ƒ MasterCard                                    ƒ VISA                                               ƒ Check (enclosed)

  (16 digits)                                         (13 or 16 digits)                                     (Make check payable to ACCC )

· If rebilling of a credit care charge is necessary, a  $25 processing fee will be charged  

· Checks not in U.S. funds will be returned

· A charge of $20 will apply to checks returned for insufficient funds

· If you fax this form, do not mail original

_______________________________________          ____________________________________

 Account Number                                                               Expiration Date

_______________________________________          _____________________________________

 Signature                                                                            Cardholder’s name (please print)

Cancellation Policy: ALL CANCELLATIONS MUST BE MADE IN WRITING. A $25 processing fee will apply to all cancellations postmarked more than 30 days before the conference.  A $50 processing fee will be charged for cancellations postmarked between 14 and 29 days before the conference.  No refunds will be made on cancellations postmarked less than 14 days before the conference.