The 19th Midwest Institute for Students and Teachers of Psychology

Online Registration Form

February 24 and 25, 2012

 

Participant Categories and Fees

Participant Category

Before 2/10/12

After 2/10/12
College Instructor $150 $175
High School Teacher $125 $150
Adjunct Faculty and Retirees $50 $75
Student $30 $50

To register online you must complete every field on the following form:

Participant Category:

First Name:

Last Name:    Title:

Institution:

Address:

City: State:   ZIP code:

Phone Number:

E-mail Address:

Credit Card Type:

Cardholder Name:     

Credit Card #:     

Credit Card Security Code #: *  

*The card security code (CSC) is usually a 3 - or 4 - digit number, which is not part of the credit card number. The CSC is typically printed on the back of a credit card (usually in the signature field). On some cards, all or part of the card number appears before the CSC, for example, 1234 567. In this example, 1234 are the last four digits of the credit card number, and 567 is the CSC.

Amount: 

Expiration Date:    Month   Year

Cardholder's Name:

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