Lilly West 2010 Conference

22nd Annual Lilly Conference on College and University Teaching - West

March 12-13, 2010

Kellogg West Ranch
California Polytechnic State University, Pomona

2010 Lilly-West Registration Form

Below you will find the form to register for Lilly-West 2010. Should you have any questions, please feel free to contact us at alliance@iats.com.

Contact info

First Name:

Middle Name/Initial:

Last Name:

Nickname for Nametag:

Department:

Institution:

Title:

Position:

Address:

City:

State/Prov.:

ZIP/Postal Code:

Country:

Work phone #: (include country code if outside US)

Fax #: (include country code if outside US)

Cell phone #: (include country code if outside US)

Email:

Emergency contact info

Contact Name: (include country code if outside US)

Contact Phone #: (include country code if outside US)

Contact Email:

Special requirements

Sign Interpreter
Wheelchair Access

Other:

Meals:

No Beef
No Poultry
No Fish
No Pork
No Dairy Products
No Eggs

Are you submitting a proposal for presentation?

Check with your Faculty Development Office or Academic VP’s office to see whether your institution is a cosponsor and/or is sending a team which would qualify you for a discounted registration rate. Teams must submit forms & payment together.

Conference Fees

Please select from the following conference packages:

At this point, all registrations need to be paid by credit card online in order to be included in this year’s conference. Credit card purchase is unavailable for team registration.

Billing

Visa
MasterCard
American Express

Credit card details

(Note: If you do not wish to submit your credit card information online, you may print a copy of this completed form, write in your credit card information, sign it, and mail it to the address above.)

Account Number:

Expiration Date:

Signature
(if mailing):
________________________________________

My billing address is the same as the one above (otherwise, complete this section)

First Name:

Last Name:

Address:

City:

State/Prov.:

ZIP/Postal Code:

Country:

Phone #: (include country code if outside US)

Other comments/requests:

Before you submit this form, please review your information, and then print a copy for your records.

International Alliance of
Teacher Scholars

Twenty-Two Years of Presenting the Scholarship of Teaching and Learning

Lilly West 2010 Conference

22nd Annual Lilly Conference on College and University Teaching - West

March 12-13, 2010

Kellogg West Ranch
California Polytechnic State University, Pomona

2010 Lilly-West Registration Form

Meals:

Conference Fees

International Alliance of Teacher Scholars

Twenty-Two Years of Presenting the Scholarship of Teaching and Learning

Lilly West 2010 Conference

22nd Annual Lilly Conference on College and University Teaching - West

March 12-13, 2010

Kellogg West Ranch California Polytechnic State University, Pomona

2010 Lilly-West Registration Form

Meals:

Conference Fees

International Alliance of
Teacher Scholars

Kellogg West Ranch
California Polytechnic State University, Pomona