You will receive a confirmation of your registration within two weeks after you submit this form via e-mail.  It will serve as your receipt.  Receipts will not be mailed or faxed.  If you do not have an e-mail address, the receipt will be provided at the conference.

(Note: An * indicates a required field.  Please use correct capitalization.)

* FIRST NAME:

* LAST NAME:

BIRTHDATE: / /

INSTITUTION:

ADDRESS (where your credit card statement is mailed):
* No. & Street:

* City:

Please enter "none" if no state/province.
*State/Province:

*ZIP/Postal Code:     Country:

TELEPHONES (U.S. residents, please include area code.  International residents, please include country and city codes.):
Home:

Work:

*E-MAIL:

* Rank:


*CONFERENCE REGISTRATION FOR (select one):


WPSA Membership rates:

There is a surcharge of $1.00 for those using a credit card (only Visa or Mastercard are accepted); a surcharge of $2.50 for postage for Canada and Mexico, and $4.00 for postage for all other foreign countries.

**You may pay for your dues now and register for the convention as a member at the same time, but you must indicate that you are paying for your membership as well. All dues paying members of the WPSA receive a subscription to the Political Research Quarterly.



* Total Amount to be Charged: $

Please note that registration fees are not refundable.

Credit Card Information (if Different from Participant):

Check here to use the name and address above

*FIRST NAME:

*LAST NAME:

* ADDRESS (where your credit card statement is mailed):
No. & Street:

*City:

if your country does not have a state or province please enter "none".
*State/Province:

*ZIP/Postal Code:     *Country:

* Credit Card Type:

* Credit Card No.:

* Expiration Date: /

three digit security code: (this is located on the back of your credit card)


Do you have an account on one of the following information technology/social media tools?

If yes, please provide the account name/address or URL where applicable
Facebook
Twitter    
Blog        

Do you anticipate the need for childcare, and would you like further information about it?

Are you a participant in the upcoming meetings?

In compliance with the Americans with Disabilities Act required under Title III, do you require special accommodation (i.e. auxiliary aids and services, accessible sleeping room, etc.)?

And explain the need here:

I authorize the WPSA to send notification of membership meetings via e-mail.

If you are experiencing problems submitting your registration or have questions about the WPSA conference, please send a message to favilaej@csus.edu.