CCCG 2013 Registration Form

Registrant Information:

 

 

 

First Name: *

Last Name: *

Affiliation: *

Street Address 1: *

Street Address 2:

City: *

Province / State:

Postal / Zip Code: *

Country: *

Email Address: *

Telephone:

Fax Number:

 

 

Payment method:

 

 

Credit card #:

Expiry date:

Signature: *

 

 

Registration Fee

Extra Banquet Tickets (C$ 70)

TOTAL

 

 

* denotes required field

 

If paying by credit card, please print the PDF, sign and send it with your credit card information by email to: wlrush@uwaterloo.ca (alternately you may fax your form to +1 519-746-5036)

If paying by cheque note that we accept only personal cheques drawn on a Canadian bank in Canadian dollars payable to the University of Waterloo

If paying by money order, please make it payable to the University of Waterloo and ensure that all banking fees are paid by you.

If paying by cheque or money order, print the registration form and send it together with your payment to:

CCCG 2013
School of Computer Science
University of Waterloo
200 University Ave W.
Waterloo, Ontario, Canada
N2L 3G1