36th Canadian High Polymer Forum
August 5 to 7, 2014, Glen House Resort, Gananoque, Ontario
Website: http://www.cerma.ulaval.ca/HPF_2014ang/
Registration Form (Please Print)
NAME:
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AFFILIATION:
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ADDRESS:
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E-mail:
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For group registration, please list all the participants below:
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Registration Fees
DELEGATE:
STUDENT AND POST-DOC:
120 $ (tax included)
60 $ (tax included)
 We will pay at the conference site (only cash accepted).
 Please charge on credit card the following amount:
Credit card info
$ ______________
Name of holder: _________________________________________
 Visa
Card Number: _______________________
 MasterCard
Expiry Date: ______________________
Signature: _____________________________________________
If paying by credit card, please send your form by regular mail or by fax as indicated below. For security
reasons, we cannot accept the e-mail submission of credit card information.
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Hotel Room Reservation
Please contact the Glen House Resort directly for reservation of the HPF package (meals included). Details will be
available on the HPF web site.
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IF PAYING BY CREDIT CARD, PLEASE RETURN THIS FORM WITH PAYMENT BEFORE JULY 18,
2014; ON SITE CASH PAYMENT WILL BE REQUIRED FOR PAYMENT AUTHORIZATIONS NOT
RECEIVED BY JULY 31, 2014.
Prof. Mario Gauthier
Secretary-Treasurer HPF2014
University of Waterloo
Department of Chemistry
200 University Ave. West
Waterloo, ON N2L 3G1
Tel: 519-888-4567, ext. 35205
FAX: 519-746-0435
Email: gauthier@uwaterloo.ca