Trillium Research Day - Primary Health Care Research Day

REGISTRATION

Primary Health Care Research Day- Trillium 2012
DEADLINE: Monday, May 28, 2012

Please note: we recognize that payment by cheque may be delayed past the registration deadline of Monday, May 28th, 2012. We will follow up if payment is not received by June 15th.

REGISTRANT INFORMATION:

Title:

Surname:

First Name:

Status:

Researcher
Clinician
Administrator
Graduate Student Resident
        (If you are a presenting Graduate student or Resident you may be eligible
         for a travel grant. If selected you will be notified by email in mid May.)
Other, please specify

Institution/Affiliation
/Company

Department

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Email:
(mandatory)

Alternate Contact Name:

Alternate Contact Email:

CONFERENCE DETAILS:

Main Discipline:
Please specify discipline:

Please select a Workshop: ( 2:40pm - 4:00 pm )
	Will fill in
	Will Fill in
	Undecided

REGISTRATION FEES:

Registration Fee: Please select appropriate fee

	Presenting	Non-Presenting
Attendee	$60.00+HST=$67.80	$75.00 + HST = $84.75
Resident/Student	Free if Lead Presenter	$40.00 + HST = $45.20

I will pay registration costs by:
Cheque (payable to "The University of Western Ontario")
Credit Card (Click here to obtain copy of form to fill out and Fax back to us)
( Mastercard or Visa only)

Did you submit an abstract?
Yes, I have already submitted an abstract.
I will be sending in my abstract.
No I am NOT submitting an abstract
Undecided