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Mentalization, Internalization, & Representation Conference
September 16-17, 2005, City College, New York
ATTENDEE INFORMATION
| Name | _______________________________________________________ |
| Degree | _______________________________________________________ |
| Address | _______________________________________________________ |
| State & Zip | _______________________________________________________ |
| _______________________________________________________ | |
| Phone | _______________________________________________________ |
| Signature | _______________________________________________________ |
Lunch is included for those registering before September 12th. Lunch will not be available to those registering after that date or at the door.
| Attendee | Before August 1st* | After August 1st* | |
| General | Two day rate:$250 One day rate: $150 |
Two day rate:$275 One day rate: $175 |
|
| Alumni & Supervisors of CUNY Clinical Psychology Program | Two day rate: $100 One day rate: $60 |
Two day rate: $125 One day rate: $85 |
|
| Graduate Students (outside of CUNY)** | Two day rate: $85 One day rate: $50 |
Two day rate: $100 One day rate: $65 |
|
| CUNY Graduate & Undergraduates** | No charge | No charge |
* There is an additional $25 fee for on site registration, and lunch will not be included. ** Please attach proof of full-time student status to qualify for reduced rates. |
Registration total: |
___________ | |
On site $25 Fee: |
___________ | ||
Total: |
___________ | ||
PAYMENT OPTIONS
| Payment Type | [ ] AmEx [ ] Mastercard [ ] Visa [ ] By Check |
| Credit Card Name | _______________________________________ |
| Credit Card Number | _______________________________________ |
| CCV # (3 digit code) | __________ |
| Expiration Date | __________ |
| Billing Address | ________________________________________ |
| State & Zip | __________________ |
If paying by check—Please make your check payable to:
City College, 21st Century Foundation, Inc. (MIR Conference)
SUBMITTING YOUR REGISTRATION
If paying by credit card—Please print, complete, and fax this form with any necessary credentials (for alumni and student rates) to: (212) 650-5673.
If paying by check—Please send your check to:
REFUND POLICYAttn: Emily Bly, MIR Conference
City College of New York NAC Building, Room 8/107
138th Street & Convent Avenue
New York, NY 10031
Refund requests must be made in writing to the above address. Requests made prior to August 15, 2005 will be refunded less a $75 processing fee. There will be no refunds made after August 15, 2005.