ONLINE VIDEO CONFERENCE REGISTRATION
Please fill out the registration form and click the submit button below. For security purposes please contact us by phone with your credit card number at 416-241-4000 x 224.
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Tax Exemption Number:		Please enter Tax Exemption Number if applicable.
DELEGATE CONTACT INFORMATION
First Name: *	Mr. Ms. Mrs. Dr.
Last Name: *
Job Title: *
Job Function:
Email Address: *
Telephone: *	(  ) - Ext:
Facsimile:	(  )  -
DEPARTMENT INFORMATION
Department Name: *		Name of department/ministry/municipality, for example: DEPARTMENT OF NATIONAL DEFENCE
Office Name:		Name of division/branch/section, for example: TELECOMMUNICATIONS DIVISION
Government Classification:	Federal Provincial Territorial Municipal State
Address 1: *
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Province/Territory/State: *	Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska America Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington-DC West Virginia Wisconsin Wyoming ******* OTHER *******
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Country: *	Canada United States
How did you hear about us: *	GOVPAGES.ca Internet Search Phone E-mail Co-worker or friend ECO-Efficiency Survey Fax Other
PRODUCT AND PRICING INFORMATION
Product Price Quantity 13% HST Total Online Video Conference $395* 0 1 2 3 4 5 6 7 8 9 10 0.00 0.00 Early Bird: Register Before May 31st, 2012 & Save $200 Off the Regular Price of $595 Individual Post Session Request (Webcast sessions can be purchased individually for $49 per presentation. Please complete the requested contact information form above and call Inderpal at: 416-241-4000 ext 224)
PAYMENT INFORMATION
Payment Type: *	Cheque
	For credit card payments please call us with your credit card information at 416-241-4000 ext.224. If you are paying by cheque, please send payment to: NCM EVENTS 59 The Westway Etobicoke, Ontario M9P 2B4 Canada
BILLING INFORMATION
Fill in Only if billing information is different than above
First Name:	Mr. Ms. Mrs. Dr.
Last Name:
Department Name:
Office Name:
Email Address:
Telephone:	(  ) - Ext:
Facsimile:	(  )  -
Address 1:
Address 2:
City:
Province/Territory/State:	Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska America Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington-DC West Virginia Wisconsin Wyoming ******* OTHER *******
Postal Code/Zip
Country:	Canada United States
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