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2011 IIPA Conference Registration Form

Personal Information:
First Name
Last Name

Address
City
State
Postal Code
Country
Home Phone Number
Work Phone Number

Email
Occupation
Degree
If paying for someone else (Conference and/or Membership), please enter their Personal Information below:

First Name
Last Name

Address
City
State
Postal Code
Country
Home Phone Number
Work Phone Number

Email
Occupation
Degree
Translations:
I/We speak English
 YES NO
I/We need translation English to
 ITALIAN SPANISH FRENCH

Conference & Membership Fees:
  Number of People
Full Conference Fee:  495 €
 1 2  
IIPA Members Fee: 445 €
 1 2  
Evaluator's Fee: 395 €
 1 2  
Saturday Banquet ticket:  50 Euros per person
 1 2  
Total Number of ADDITIONAL Banquet tickets for a friend/companion/spouse who is not attending the conference
1 2
If you are purchasing additional Banquet tickets,
please enter their names here
Total Amount of Conference Fees
   

I wish to pay my 2010 IIPA dues now

 YES NO
2010 Regular Membership:  65 €
  
2010 Certified Psychotherapists and Counselors: 100 €
  
2010 Certified Trainers: 135 €
  
   
I wish to pay my 2011 IIPA dues now
 YES NO
2011 Regular Membership:  65 €
  
2011 Certified Psychotherapists and Counselors: 100 €
  
2011 Certified Trainers: 135 €
  
     
Total Dues Payment

If you are not paying your dues, please ignore this Directory section and go to TOTAL PAYMENT

Do you wish to be listed in the IIPA Directory?
 YES NO
Do you wish to have your work phone listed?
 YES NO
Do you wish to have your email listed?
YES NO
Website for Directory
TOTAL PAYMENT

Payment can be made by: (please check one)

CREDIT CARD

Visa MasterCard Expiration Date (MM/YY)
Name on credit card
Account Number
CVVS Code (Visa/Master/Card: 3-4 digits at the end of numbers on upper right side of signature strip.)

DIRECT BANK (WIRE) TRANSFERS
After completing this registration form, please instruct your bank to send your payment to the following bank account:

Account number (IBAN): FR76 1830 6000 6511 8713 6310 866
Name of the account: ASSOC DES AMIS DU CONGRES IIPA

Address: 3 RUE FOULD
City: 78600 LE MESNIL LE ROI
Country:  FRANCE

Data of the bank in France:
Swift (BIC):  AGRIFRPP883
Name:  CREDIT AGRICOLE NORMANDIE SEINE

Address: AVENUE RENE COTY
City:  76600 LE HAVRE
Country:  FRANCE


CHECK OR MONEY ORDER

While we will accept checks designated payable in Euros, we prefer to receive international money orders for Euros

Payable to: ASSOC DES AMIS DU CONGRES IIPA

Please send the check or money to:

THIERRY CLUGERY
81 RUE LOUIS DELAMARE
76600 LE HAVRE
FRANCE



PLEASE CLICK THE SUBMIT BUTTON ONLY ONCE
It may take a few moments to process your order.

  

Cancellations must be submitted in writing by February 1, 2011 and will be subject to a 20 Euros service charge
No refunds will be issued after February 1, 2011

If you have further questions about conference registration please contact
our Registrar, Thierry Clugery at: contact@congres-iipa2011.com

For more information about the conference, write to
Grace Slottje at: contact@congres-iipa2011.com