Conference Registration Event Registration Please complete the information below to register for the conference. FCIE Event Registration FormFirst and Last Name*Institution*Phone*Email* Affiliation* FCIE Study Florida FAIE Please select your choices* One-day registration Two-day registration I am a presenter Meals Attending* Thursday, Oct. 6 Lunch 12:00-1:15 p.m. Thursday, Oct. 6 Banquet Dinner 6:00-9:00 p.m. Friday, Oct. 7 Lunch 12:00-1:00 p.m. I am requesting vegetarian meals. Indicate the number and type of additional tickets you need (lunch $25 each; dinner banquet $40 each)Total Amount to ChargeName on the Credit CardCredit Card NumberExpiration Month01-January02-February03-March04-April05-May06-June07-July08-August09-September10-October11-November12-DecemberExpiration Month2014201520162017201820192020Security CodeCredit Card Billing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Authorization*Please enter your name here. By clicking on the Submit button below, you are authorizing Valencia College, on behalf of FCIE, to process this credit card charge for the amount indicated above. EmailThis field is for validation purposes and should be left unchanged.