REGISTER by FAX
Please complete this form, print it, and FAX it (if you're paying by credit card) to John Ujvari at 919.962.3291.
Please call John at 919.962.8297 should you have questions.
FIRST NAME:
LAST NAME:
BUSINESS AFFILIATION:
TITLE:
NAME ON NAMETAG:
BUSINESS ADDRESS:
CITY:
STATE:
ZIP:
BUSINESS PHONE:
E-MAIL ADDRESS:
I wish to register for the free SBIR Introductory session (8-9:15am).
Please use VISA or MasterCard only
It is mandatory that you complete the following credit card information if you want to preregister for this event.
Card type: VISA MasterCard
Card #
TYPE OF REGISTRATION:
CHOOSE ONE: Full-day (including lunch) @ $75 Afternoon workshop only @ $60
Expiration date:
Name (on card):
Typed signature:
(NOTE: Statement will list payment to "University of North Carolina at Chapel Hill")
