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University of the Virgin Islands Caribbean Exploratory Research Center 10th Annual Health Disparities Institute St Thomas, USVI — October 18-20, 2017 Frenchman’s Reef & Marriott Beach Resort INSTRUCTIONS: Complete this Registration Payment Form and email or post it to: Dr. Gloria B Callwood, Director — Caribbean Exploratory Research Center University of the Virgin Islands, 2 John Brewers Bay, US Virgin Islands 00801 Download, complete and save this PDF to your computer then attach it to an email addressed to: CERCSecretariat@uvi.edu Title: Prof. Dr. Mr. Mrs. Ms. Other: Full Name: University/Organization Name: University/Organization Address: Email Address: Mobile Phone Number: Presenter Non-Presenter Registration Type USVI Residents General Student Amount USD Early-Bird On or Before Sept. 18, 2017 $250 $325 $125 Pre-Registration On or Before Oct. …
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University of the Virgin Islands Caribbean Exploratory Research Center 10th Annual Health Disparities Institute St Thomas, USVI — October 18-20, 2017 Frenchman’s Reef & Marriott Beach Resort INSTRUCTIONS: Complete this Registration Payment Form and email or post it to: Dr. Gloria B Callwood, Director — Caribbean Exploratory Research Center University of the Virgin Islands, 2 John Brewers Bay, US Virgin Islands 00801 Download, complete and save this PDF to your computer then attach it to an email addressed to: CERCSecretariat@uvi.edu Title: Prof. Dr. Mr. Mrs. Ms. Other: Full Name: University/Organization Name: University/Organization Address: Email Address: Mobile Phone Number: Presenter Non-Presenter Registration Type USVI Residents General Student Amount USD Early-Bird On or Before Sept. 18, 2017 $250 $325 $125 Pre-Registration On or Before Oct. 6, 2017 $275 $375 $175 On-Site Registration $300 $400 $175 Day Rate $150 $225 $100 Undergrads Graduates Professionals Pre-Institute Workshop Registration $20 $30 $50 TOTAL: PAYMENT METHODS AND INSTRUCTIONS (Cash is not accepted) Check One Payment by Money Order or Bank Check (Not Personal Check): Make payable to "CERC — University of the Virgin Islands." Mail to the above address, together with this Registration Payment Form. Note: Please email a scanned copy of the check to the Director before mailing the original. You will receive a receipt via email. Payment by Credit Card by Email: Complete the information required below and email this Registration Payment Form to the Director to forward to the UVI Cashier for processing. You will receive a receipt via email. Payment by Credit Card by phone: Call the UVI Cashier’s office directly for them to take the credit card details over the phone. 340-693-1437 or Mr. Robert Chen at 340-693-1143. State it is for Conference Fees for the CERC Institute Account No. 260239, and provide your name and email address. You will receive a receipt via email. Note: You still need to complete and email this Registration Payment Form to the Director (but only enter the last four digits of the credit card number). UVI Faculty/Staff Members: Name of School/College paying your Registration Fees Dean’s Signature Date: PLEASE CHARGE MY: MASTERCARD VISA NAME ON CARD: CARD NUMBER: EXPIRATION: 3-DIGIT SECURITY CODE: $0.00 Enter date as MM/YYYY