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Mail To: 
Registration Services
The University of Alabama, Box 870398, Tuscaloosa, AL 35487

CSIC Participant Registration

Bryant Conference Center 240 Paul W. Bryant Drive Tuscaloosa, AL 35401
February 29, 2020
Program # 07-367-20

Student Rate: [ ] $35    

Student Group Rate (5-9 students registered at one time): [ ] $25 

Large Student Group Rate (10+ students registered at the same time): [ ] $20   

Professional Rate [ ] $99

Professional Group Rate (5-9 participants registered at one time): [ ] $89   

Large Professional Group Rate (10+ participants registered at one time): [ ] $79

Please submit this entire page for your registration. For multiple registrations, please duplicate this form.

[ ]Mr. [ ]Ms. [ ]Dr. First:____________________________Middle Initial:________Last:____________________________

Preferred Name/Nickname:____________________________

Company/Organization Name:____________________________

Mailing Address:____________________________City:____________________________State:________Zip:______________

Email Address:____________________________Phone:____________________________

Job Title:____________________________

[ ] Enclosed is a check for $____________________________ made payable to THE UNIVERSITY OF ALABAMA

[ ] Purchase order is attached.

[ ] Charge $____________________________to credit card: [ ] MasterCard [ ] VISA [ ] American Express [ ] Discover

Card #____________________________Exp. Date (M/Y)____________________________

Security / Verification / CVV Code____________________________(Three or four digit code on back or front of credit card.)

Authorizing Signature:____________________________