NMR Course Registration

Online Form

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WE RECOMMEND REGISTRATIONS BE SENT 4 WEEKS PRIOR TO COURSE DATE

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Name:	----------	Title:
(As you would like it to appear on your certificate)	----------	Office Phone:
Business Name/Address:	----------	Home Phone:
	----------	Fax #:
	----------	E-mail Address:

NMR Concepts maintains a NON-DISCRIMINATORY POLICY for all who wish to attend any of its courses. NMR Concepts admits anyone regardless of race, color, national or ethnic origin to all rights, privileges, programs and activities accorded to attendees of its courses. It does not discriminate on the basis of race, color, national and ethnic origin for registration of attendance of its courses, nor for its discount policy for full-time faculty, university staff, or graduate students attending an accredited university or college.

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In addition to the course fee, a $100.00 US non-refundable registration fee is required for each course. Labs cannot be taken unless in conjunction with a course. Registrations will not be accepted for a lab without previous or present attendance to the corresponding course. No registration fee is required for the lab. A 3% bank processing fee will be charged for all payments via credit card.

Please check the appropriate boxes:
Course Title and Number:	Date:	Fee:
NMR Concepts & Operating Techniques, #100	March 27 – Apr 1, 2011	$1,350,00
NMR Concepts & Operating Techniques Lab, #100L	April 2, 2011	$450.00
Interpretation of 1D and 2D NMR Spectra, #110	May 22 – May 27, 2011	$1,450,00
Interpretation of 1D and 2D NMR Spectra Lab, #110L	May 28, 2011	$450.00
NMR Concepts & Operating Techniques, #100	Oct. 2 – 7, 2011	$1,350.00
NMR Concepts & Operating Techniques Lab, #100L	October 8, 2011	$450.00
Interpretation of 1D & 2D NMR Spectra, #110	Nov 13 – 18, 2011	$1,450.00
Interpretation of 1D & 2D NMR Spectra Lab, #110L	November 19, 2011	$450.00

Payment Method:

Check, payable to: Nuclear Advancement Corporation, P.O. Box 96, Van Wyck, SC 29744-0096
Government Purchase Order
Credit Card	Visa Master card American Express
Credit Card Number and Security Code:		Exp. Date:
Registration Fee:	$	($100 x number of courses)
Course/Lab Fee:	$
3% Bank Processing Fee:	$
Total to be charged:	$

Electronic Signature:

Hotel Reservations:
Please complete for all hotel reservations:
Do NOT make hotel reservations.

Please MAKE hotel reservations.

Single Room
Double Room	(roommate's name, IF attending)
Non-Smoking
Smoking
Arrival Date:
Departure Date:
Please provide credit card number to guarantee hotel reservations:
Credit Card Number:	Exp. Date:

I am driving, please send a map with directions to the hotel.

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Pre-Course Questionnaire:

Name:

(as you like it to appear on your name tag)

Please provide the following information:
1. Most recent degree, institution, and date

2. Present field of study/research:

3. a. Type and model of instrument presently used:
3. b. Type and model of intrument previously used:
4. a. Number of years interpreting NMR Spectra:
3. b. Number of years operating an NMR Instrument:
5. Experiments you presently feel competent in running:

6. Experiments you would like to learn more about:

7. How much experience have you had in the subject matter of the course:

None	Some	Considerable
(if 'considerable,' please elaborate below)

8. Please select (Ctrl + Click) all areas that apply to your research:
Organic Inorganic Organometallic Polymers Biological Peptides Solutions Solids Other

9. What would you like to gain from this course?

10. Please enter any additional comments here: