University of Connecticut CTI Technology Transfer Center

On-Line Registration Form

** Indicates a required field


**Workshop/Event Title:
Date(s):
Full day A.M. Session P.M. Session
**Workshop Location:
**Applicant Name:
**Title:
**Agency/Municipality/Other:
**Mailing Address:


**Work Phone:
**Fax#:
**Email address:

Question or Topic for Discussion:


BILLING INFORMATION (not required unless there is a registration fee for the session)

Billing Contact Name:

Billing Contact Phone#:

Billing Address same as above:

Billing Address:



Do you have a need for special services or arrangements?
Yes, please contact me regarding the need for special arrangements


E-Mail:

Please Add me to your Mailing List
Please Add me to your Public Works Listserv
Please Add me to your LTA Listserv


REGISTRATION FEE PAYMENT:

Sending check in the mail

Purchase Order/Voucher (enter #)::

Payment is due prior to the date of the workshop.
If paying by check, please make payable to UConn and
mail to:

Technology Transfer Center
Attn: Carolyn Ward
270 Middle Turnpike, Unit 5202
Storrs, CT 06269-5202

BEFORE submitting...PRINT or "SAVE AS..." a copy of this registration for your records.
Be sure you have entered ALL information requested.

Submit form:

A confirmation of your registration will be sent to you soon.

Cancellation Policy: If your plans change and you cannot attend, a colleague may attend in your place - just send us a fax or letter. Cancellations and requests for refunds must be made in writing. Full registration fee is refundable if notice is received 10 days prior to the start of the workshop. No refund of the registration fee will be made if you are unable to attend and do not cancel in advance.

      
Technology Transfer Center
270 Middle Turnpike, Unit 5202
Storrs, CT 06269-5202
(860) 486-5400