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= Required Fields
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Date
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First Name:
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Last Name:
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Position/Title:
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Name as it should appear on badge:
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Institution/Association/Organization:
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Mailing Address:
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City:
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State/Province:
If from a Country other than USA or Canada, Please select the first option "OTHER" in the dropdown below
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Zip:
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Country:
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Phone:
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Fax:
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Email Address:
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- Please select appropriate category:
You may select to submit a membership application below and pay member conference fees.
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Registration before February 1, 2012
Member - $375.00 per person
Non-Member - $550.00 per person |
Registration after February 1, 2012
Member - $425.00 per person
Non-Member - $600.00 per person
Notes: The above registration fees include all conference meals and the cocktail reception on February 25 that will be held with the National Association of Community College Teacher Education Programs.
Non-members will be given temporary membership status for one year.
Registration may be canceled for a full refund up to thirty days before the conference. Cancellations made up to two weeks before the conference will be charged a $100 cancellation fee. Cancellations will not be accepts within two weeks of the conference. |
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- optional with conference registration
Institutional Membership $500.00 - If submitting the institutional membership, all individuals attending the conference from the institution will receive the member registration rate.
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Individual Membership $150.00 |
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Check to follow
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Check attached
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Charge Membership Fee
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Card Holder Name:
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Billing Address:
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Expiration Date:
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Card Number:
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Card Type:
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Please enter the code to continue.
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or
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If you are mailing this form, please return this form with your check (Payable to Community College Baccalaureate Association) or credit card information to:
Beth Hagan, Ph.D.
Community College Baccalaureate Association
c/o Edison State College
25216 Pelican Creek Circle, #103
Bonita Springs, Fl 34134
If you pay by credit card, and do not want to use e-mail, you may fax your application to 239-947-8870.
Note: The CCBA name will not appear on your credit card statement. The processing organization, Business Solutions of Naples will be shown. |
