2017 CIPC Conference Packet | Page 22

Membership Payment Form - Part II

Method of Payment American Express MasterCard Visa Check #_________ Credit Card #: ____________________________ Exp . Date ( MM / YY ): _________ CVC #: ____________ Credit Card Billing Address : _____________________________________________________________ City : __________________________________ State : ___________________ Zip : _________________ Name on Card ( Please Print ): ____________________________________________________________ Signature ( Required ): ____________________________________________ Date : _________________ Attendee Registration First Name : _________________________________ Last Name : _______________________________ Badge Name ( if different from above ): _____________________________________________________ Title / Position : ________________________________ E-mail : __________________________________ Phone : ________________________________________ Fax : _________________________________ Mailing Address : ______________________________________________________________________ City : __________________________________ State : ______________________ Zip : ______________ Attendee Registration First Name : _________________________________ Last Name : _______________________________ Badge Name ( if different from above ): _____________________________________________________ Title / Position : ________________________________ E-mail : __________________________________ Phone : ________________________________________ Fax : _________________________________ Mailing Address : ______________________________________________________________________

City : __________________________________ State : ______________________ Zip : ______________

Please send completed Membership Payment Forms Part I & II . Confirmations will be sent once your payment has been processed .

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