Supporter Registration Form

Complete one per company.

Company Name:

Address :_____

Registration Type

Code / Description / Fee per person / Access
EXH / Exhibit stand personnel only / $ 0 / Exhibits only
COMP / Complimentary per Support package / $ 0 / Exhibits and scientific sessions
DISC1 / Discount per Support package through 4 Sept / $ 400 USD / Exhibits and scientific sessions
DISC2 / Discount per Support package 5 Sept-21 October / $ 475 USD / Exhibits and scientific sessions
DISC3 / Discount per Support package after 21 October / $ 550 USD / Exhibits and scientific sessions
TOUR / Optional Night Safari Networking Tour / $ 50 USD / 6 November

Personnel

*CODE(S): Please include Registration Type (EXH, COMP, DISC) per person and include TOUR where applicable.

First Name: Family Name: *Code(s):

Email: Phone:

First Name: Family Name: *Code(s):

Email: Phone:

First Name: Family Name: *Code(s):

Email: Phone:

First Name: Family Name: *Code(s):

Email: Phone:

First Name: Family Name: *Code(s):

Email: Phone:

First Name: Family Name: *Code(s):

Email: Phone:

First Name: Family Name: *Code(s):

Email: Phone:

Payment Information (if applicable)

Payment must be received by 21 October 2014. All payments must be in USD.

 Check

Make all checks payable to International Society for Stem Cell Research

Mail to the ISSCR:

International Society for Stem Cell Research

Attn: ISSCR-SCSS Regional Forum Registration

5215 Old Orchard Road, Ste. 270

Skokie, IL 60077 USA

 Wire

PAYMENT BY WIRE TRANSFER
The information below is necessary for all wire transfers into ISSCR's bank account:
To Beneficiary:
International Society for Stem Cell Research
5215 Old Orchard Road, Ste. 270
Skokie, IL 60077 USA
Account number 10172578 / Bank Information:
American Chartered Bank
1199 E. Higgins Rd
Schaumburg, IL 60173
ABA# 071-925-046
Swift: AMCDUS41
We request an additional $45.00 USD wire fee processing charge for each incoming wire.

 Credit Card

□ VISA □ MasterCard □ American Express Amount: $ USD

Card Number Expiry Date

Authorized Signature Date

Return to no later than 21 October 2014.

International Society for Stem Cell Research

5215 Old Orchard Road, Suite 270

Skokie, IL 60077 USA www.isscr.org Tel: +1-224-592-5700 Fax: +1-224-365-0004

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