Registration Form

You are registering for:

Please tell us about yourself:
(Fields marked with an * are mandatory)

*Name

Title

Organization

Street Address

City

Province

Postal Code

Country

*Work Phone Use format: (555)555-5555

Fax

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Affiliation:

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Who referred you to our seminar?

Dietary Restrictions:

Payment information:

Credit Card (A CLBC staff member will telephone you to obtain your credit card information.)
Cheque (Please send your cheque by mail to CLBC, 340 MacLaren Street, Ottawa, ON, K2P 0M6)

*Name
Title
Organization
Street Address
City
Province
Postal Code
Country
*Work Phone	Use format: (555)555-5555
Fax
E-mail