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Incorrect checks will be returned registration voided. Send payment payable to University of Maryland and registration form to IPMC Department of Entomology University of Maryland College Park MD 20742 REGISTRATION FORM WITH PAYMENT MUST BE RECEIVED BY FRIDAY JANUARY 15 2010 2. Please check appropriate category PCO/PMP SPEAKER CONFERENCE WORKER USE ONE COPY OF FORM FOR EACH PERSON Please copy blank form if additional forms are needed IPMC REGISTRATION FORM The Interstate Pest Management Conference January 27 and 28 2010 REGISTRATION MUST BE RECEIVED BY FRIDAY JANUARY 15 2010 NAME Last Name First Name and Middle Initial HOME ADDRESS Street City State Zip Code BUSINESS OR AGENCY Name Phone Check the State s in which you are certified MD DC VA NJ PA CT WV DE Other KY Not Certified Please check the conference s you plan to attend Conference I Wednesday January 27 2010 125. 00 Thursday January 28 2010 Both Conferences METHOD OF PAYMENT Check or Money Order Mail with reg* Form Discover 16 digits Visa 13 or 16 digits Mastercard 16 digits American Express 15 digits Exp* Date Month Year Bank Code 3 or 4 digit code on back of card Name as it Appears on the Card Signature 1. If mailing include registration form and check or money order for the correct amount NO CASH. Make check or money order payable to UNIVERSITY OF MARYLAND only. PREREGISTER EARLY. SPACE IS LIMITED 3. Your cancelled check is your receipt. 4. Due to obligations for meals and space money cannot be refunded after JANUARY 22 2010. 00 Thursday January 28 2010 Both Conferences METHOD OF PAYMENT Check or Money Order Mail with reg* Form Discover 16 digits Visa 13 or 16 digits Mastercard 16 digits American Express 15 digits Exp* Date Month Year Bank Code 3 or 4 digit code on back of card Name as it Appears on the Card Signature 1. If mailing include registration form and check or money order for the correct amount NO CASH. Make check or money order payable to UNIVERSITY OF MARYLAND only.

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