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Sponsored by: UC Institute
for
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How to Register
Registration Deadlines
Registration Fees Payment
Credit Card Information
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Name as it appears on the card
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Credit card number and expiration date
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Signature
Type or PRINT clearly:
Name:______________________________________________________________________
First Middle Last
Name as Preferred on Badge:________________________________________________
Affiliation:_______________________________________________________________
Title:_____________________________________________________________________
Address:___________________________________________________________________
City:____________________________ State:_____________ Zip:_________________
Phone: _________________________________ Fax:______________________________
Email: ____________________________________________________________________
Dietary/access requirements: ______________________________________________
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