Registration Form

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Name

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Badge Name (Name as it is to appear on badge)

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Company

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Address

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City State Zip

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Telephone

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E-mail Address

Indicate all that apply:

______FCAS ______ACAS ______CAS Candidate ______CAS Subscriber

______Affiliate Member ______Academic Correspondent

Other ___________________________________________

Registration Fees

(Includes any seminar materials, continental breakfasts, luncheon, refreshment breaks, and receptions)

Method of Payment

¨ Check enclosed for the amount ___________________

¨ Credit Card for the amount ______________________ (please check one):

¨ Visa ¨ MasterCard ¨ American Express ¨ Diners Club ¨ Discover

Card Number: _____________________________Expiration Date: _________________________

Cardholder’s Name: _______________________________________________________________

Billing Address: ___________________________________________________________________

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Signature (Credit Card payments will not be processed without a signature)

¨ Please check here if you have any special requirements due to disability

¨ Dietary restrictions: _________________________________________

If paying by check
Complete this form and send with check made payable to:
Casualty Actuarial Society
P.O. Box 425
Merrifield, VA 22116-0425

If paying by credit card
Complete this form and return to:
Casualty Actuarial Society
1100 North Glebe Road
Suite 250
Arlington, VA 22203-4798

OR fax to: (703) 276-3108

If you fax in your registration with credit card information, please do not submit the original form as well– this may cause a duplicate charge to your credit card. All Credit Card payments will be processed in U.S. Dollars

Note: Registration fees will be refunded for cancellations received by March 23, 2001, to the CAS Office, less a $50 processing fee. Only written cancellations will be honored. Fax or e-mail cancellation requests to (703) 276-3108 or e-mail to kdean@casact.org.