2018 CIPC 2018-CIPC Conference Information Packet | Page 21

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. Check Payments: (payable to MarketScout) Mail to: MarketScout/Diahann Doyen 12700 Park Central Drive, Suite 300 Dallas, TX 75251 Tel: [phone] Email: [email protected] Credit Card Payments: Return with form to [email protected] or fax at 972-934-4299 www.privateclientcouncil.com