CONFERENCE REGISTRATION FORM

SOUTHEAST CONFERENCE ON LANGUAGES AND LITERATURES

StetsonUniversity, DeLand, Florida

March 2-3, 2012

(Please Print)

Name: _________________________________________________________________

Academic Affiliation :________________________________________________________________

Registration Fee: $110 until February 7
$125 after February 7 or at Conference

$60 for graduate students until February 7
$75 for graduate students after February 7

Make checks payable to: Stetson University

Credit card payment: visa card or MasterCard (issued by a bank), Discover, no debit cards please :

Card Holder Information:

Complete billing address:

Street, nbr, apt. ___________________________________________________

City, State, zipcode: _________________________________________________

Phone:_______________________________

Fax:_________________________________

E-mail: ______________________________

Name as it appears on card: ______________________________
Card #: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
expiration date: __ __ / __ __
security code: ___ ___ ___

I authorize StetsonUniversity to charge my credit card the amount of $________

Signature: _____________________________________________

All rooms will be smart classrooms

for other concerns or requests e-mail Yves-Antoine Clemmen, Conference director at yclemmen@stetson.edu

Mail or fax this form :

Stetson University
Department of Continuing Education
421 N. Woodland Blvd., Unit 8393
DeLand, FL 32723
Phone: (386) 822-7500
Fax: (386) 822-7502