2014 CAMBRIDGE BIOSAFETY FORUM REGISTRATION FORM
Registrant Name __________________________________________________
Currently serving as IBC Community Representative?
Yes
□
No
□
Company Name (if applicable) ________________________________________
Registrant Address: ________________________________________________
City: ___________________ State__________ Zip _________
Phone: _________________________
Email ___________________________________________________________
PAYMENT INFORMATION



Cambridge permit holders sponsoring one or both of their Community Reps
Individuals not planning to serve as a Community Representative
Individuals who plan to serve as a Community Representative
$150
$50
$0
Please make your check payable to: Cambridge Public Health Department and
mail to: Ashleigh Allard, Safety Partners, Inc.,19A Crosby Drive, Suite 300,
Bedford, MA 01730. We cannot accept credit cards at this time. If you cannot
generate a check before the first night of the training, please contact Sam Lipson at
slipson@challiance.org. No one will be denied participation if they have submitted
this registration form and received confirmation.
If payment is being made by a sponsoring company or institution:
Company Name ___________________________________________________
Company Contact (for billing) ________________________________________
Billing Address (if different than above) _________________________________
City: ___________________ State__________ Zip _________
Phone: _________________________ Email ____________________________
Please email or fax registration form to: Ashleigh Allard, Safety Partners, Inc.,
email: aallard@safetypartnersinc.com or fax: 781-222-1022.
119 Windsor St.  Ground Level  Cambridge, MA 02139
617.665.3800  Fax 617.665.3888