The Pb-Free Electronics Risk Management (PERM) Council Meeting No. 23 February 3-5, 2015 Aerospace Vehicle Systems Institute (AVSI) at Texas A&M University, College Station, TX 1. REGISTRANT CONTACT INFORMATION Title (Dr. Mr. Ms.): FIRST NAME: LAST (Family) NAME: Job Title: Mail Stop: Company: Business Address: City: State: Telephone No. (Include Country/City/Area Code: Registrant’s E-mail: Country: Ext.: Zip/Postal Code: Cell/Mobile Phone: Alternate E-mail address: Please check here if you have special dietary or physical needs. IPC will contact you for details. Check here if you do NOT want your contact information shared with event sponsors or other attendees. How did you hear about this event? Brochure was mailed to me Colleague E-mail Trade Magazine Other (Please specify ) 2. REGISTRATION FEES OPTION Registration Fee for the Pb-Free Electronics Risk Management (PERM ) Council Meeting No. 23 TOTAL $75 $75 3. METHOD OF PAYMENT Check. Make check payable to IPC and mail with form to: IPC, 3491 Eagle Way, Chicago, IL USA 60678-1349. Purchase Order (IPC Members Only) Credit card (select one): Visa Reference Purchase Order # Mail invoice to: Master Card American Express Diners Club Account Number Expiration Date (Month/Year): Billing Address: Cardholder Name: Signature: Cardholder Telephone Number: Cardholder E-mail: If you are unable to attend, you may send a coworker in your place. Please notify us of name changes or the need to cancel by January 29, 2015 to make arrangements for substitution or full refund. If you have any questions, contact IPC’s Registration Department at +1 847-597-2861 or firstname.lastname@example.org.