Conference Registration Cancellation Form

Name of registrant:(*)

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Registrant’s email address:(*)

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Institution/organization:(*)

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Street address:(*)

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City:(*)

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State:(*)

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ZIP (postal) code:(*)

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Phone number (incl. extension):(*)

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Registration reference number:

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Name of person submitting this form (if not the registrant):

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Submitter’s email address:

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Reason for cancellation:

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