BSC Registration Form 1st Annual Meeting of the Biophysical Society of Canada (BSC) Conference, hosted by the University of Waterloo, June 17-19, 2015. Important Registration Information! 1. Each registrant must complete the form below. It contains non-sensitive information that will be used to prepare an invoice for each registrant. BSC members who wish to qualify for a reduced/free registration must send confirmation/receipt of your BSC membership payment with this form and send via email to Krystina Bednarowski at kbednarowski@uwaterloo.ca. 2. An invoice with payment instructions will be emailed to you in approximately 2 weeks of submitting the form. 3. Your registration will be considered complete when payment of the invoice (via cheque or credit card) is received in full. Payments made by credit card will be accepted through the University of Waterloo secure invoice processing website. If you have questions regarding registration, invoicing, or payment, please email or phone Krystina Bednarowski at 519-888-4567 (ext 32732). The deadline for early registration is May 31, 2015. REGISTRATION AFTER MAY 31: BSC Members $150 Non-Members $250 Student Members $50 Student Non-Members $150 Government/Industry Participants $350 Exhibitors & Sponsors $1,000 CANCELLATION POLICY: 100% refund up until April 30, 2015 50% refund from May 1 – May 31, 2015 No refunds after May 31, 2015 1. Registration Type Please choose your type of registration. All dollars are in Canadian. ☐ BSC Members - $100 ☐ Non-Members - $200 ☐ Student Members - Free ☐ Student Non-Members - $100 ☐ Government/Industry Participants - $300 ☐ Exhibitors & Sponsors - $1,000 (includes 1 registration fee, 1 booth (table + poster board), and company name on BSC 2015 website) Page 1 of 3 BSC Registration Form 2. Personal Information Prefix: First Name: Last Name: Email Address: Personal Address: Street Address: City: Province/State: Postal or ZIP Code: Country: Telephone Number: Mobile Number: Institution, Company, and Department: 3. Billing Address Please fill this out only if the billing address is not the same as above. Street Address: City: Province/State: Postal/ZIP Code: Country: Page 2 of 3 BSC Registration Form 4. Do you require any special dietary considerations? ☐ Vegetarian ☐ Gluten-Free ☐ Other: 5. If you have a disability or condition that requires accommodation to support your participation, please provide details below: Please email the completed form to Krystina Bednarowski at kbednarowski@uwaterloo.ca. Page 3 of 3