IM-XI Registration | Adastra Corporation

Please complete the following form accurately

Titre
* Prénom	Main Registrant First Name :
* Last Name	Main Registrant Last Name :
Preferred Name
* Job Title	Main Registrant Job Title :
* Business Phone	Main Registrant Business Phone :	Ext
Business Fax
* Business Email	Main Registrant Business Email :

	If you would like your Manager, Administrative Assistant, or Colleague to receive a copy of all your conference email notifications, including registration confirmation, please add a CC recipient and enter his or her email address.

* Company Name	Main Registrant Company Name :
* Street Address	Main Registrant Street Address :
* Ville	Main Registrant City :
* Prov/State	Main Registrant Prov/State :
* Postal Code/Zip	Main Registrant Postal Code/Zip :

Do You Have Any Dietary Restrictions?	Oui Non
Please Specify
Special Considerations
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How Did You Hear About the Conference?
Please Specify
Have You Attended Our Previous Conferences?	Oui Non