Leadership Conference Cancellation and Change of Attendee Form: Add

Cancellation

Institution/Organization:

Full Name of Registrant to be Canceled:

Please include first and last name of the registered person at your institution or organization.

Cancellation Fees:

Cancellation Fee Schedule:
- $50 cancellation fee (Through January 8)
- $75 cancellation fee (January 9-22)
- $100 cancellation fee (January 23-28)
- $0 refund on January 29 and later (review Cancellation Due to Illness policy for potential exceptions)

Reason for Cancellation:

Pre-Payment Method:

If pre-payment was made by check, refund check should be payable to:

Address:

Address 2:

City:

State:

Zip Code:

Phone Number:

Email Address:

If paid by credit card, please provide the last four digits of the credit card used to make the original credit card payment:

Credit Card Type:

Expiration Date:

mm/yy

Name as it Appears on Card:

Change of Attendee|<a id="change"></a>

Full Name of Registrant to be Canceled:

Please include first and last name of the registered person at your institution or organization.

Institution/Organization:

Phone Number:

Email Address:

Full Name of New Attendee:

Please include first & last name.

Is this your first conference?:

Title:

Institution/Organization:

Address:

Address 2:

City:

State:

Zip Code:

Phone Number:

Email Address:

Form Submitted By

Name:

Email Address: