2017 MW CTR-IN 4th Annual Meeting Registration Form

IDeA Programs Collaboration in the Mountain West Region

May 15 – 16, 2017

Please submit this registration form by Friday, April 28, 2017.

Please send all inquiries to ctr-in@unlv.edu

Upon completing this registration form, please book your airline arrangements with Kozals Travel.

MW CTR-IN Airline Policy:
As a regular attendee, the MW CTR-IN will only support airline travel that is the most cost efficient as scheduled with our Travel Agency, Kozals Travel.

Kozals Travel
Gaylene Stephens
Phone: 702-798-1004
Email: gstephens@kozals.com

Please provide the agent with the following information with your request:

(1) Name as it appears on government issued id (like a driver’s license)
(2) Departure city
(3) Dates of travel
(4) Date of birth
(5) Gender
(6) Mobile phone contact – for the airline
(7) Name of airport you will be departing from
 

MW CTR-IN Lodging Policy:
As a regular attendee, the MW CTR-IN will only support your hotel stay at the Signature Hotel for Sunday and Monday nights (May 14 – 15th, 2017), unless extenuating circumstances (e.g. flight scheduling issues, etc.) require an additional night of stay on Tuesday night (May 16th, 2017).

 
HOTEL ACCOMMODATIONS
Please note that your hotel room has been reserved at The Signature at MGM Grand.

REGISTRATION FORM

First Name (required)

Last Name (required)

Degree(s) (required)

Title (required)

University/Institution (required)

If Other Selected Enter University/Institution below

Department (required)

Your Email (required)

Address (required)

City (required)

State (required)

Zip (required)

Work phone number (required) eg. (123) 345-6789

Cell phone number eg. (123) 345-6789

Will you be driving to the meeting and need a campus parking pass?
No Yes 
If Yes, Which days will you need a parking pass? Check below all that apply.
 Sunday, May 14th Monday, May 15th Tuesday, May 16th Wednesday, May 17th

Will you be lodging at The Signature Hotel?
No Yes 
If Yes, Which days ? Check below all that apply.
 Sunday, May 14th Monday, May 15th Tuesday, May 16th Wednesday, May 17th

Will you be attending the Networking Dinner Reception (at the Smith Center for the Performing Arts in Las Vegas; Address: 361 Symphony Park Ave.) on Monday, May 15th at 6:30 p.m.?
No Yes 

Are you a MW CTR-IN committee member?
No Yes 
If Yes, Check below all that apply.

Special Needs/Food Allergies – fill in box below

Please check the box next to your scientific areas of interest:

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Mountain West CTR-IN

The CTR-IN program is supported by the NIH through the National Institute of General Medical Sciences (NIGMS) #1U54GM104944-01A1 under the Institutional Development Award (IDeA) program.

CTR-IN Main Portal

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