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Churchill perspectives on leadership 30th INTERNATIONAL CHURCHILL CONFERENCE - OCTOBER 31 - NOVEMBER 2, 2013

Registration FORM NAME(S):____________________________________________________________________________________________ ADDRESS:_ __________________________________________________________________________________________ CITY:_____________________________STATE/PROV:________ ZIP/POSTAL CODE:_____________ COUNTRY:_ ______________ PHONE: _______________________________________ EMAIL ADDRESS:__________________________________________ PREFERRED NAME(S) FOR YOUR BADGE(S): (1) _______________________ (2) ________________________ FIRST TIME ATTENDEE? YES _____ NO _____

All Prices Quoted in U.S. Dollars and are Per Person, unless otherwise noted Spouses or partners are considered _ members for registration purposes Tax Deduction Shown is amount allowed for US registrants.

EARLY BIRD DISCOUNT - Register before July 1, 2013 and take 10% off Registration or Package Price □

Chartwell Club Package (US Tax deduction: $1,103 couple/$442 single) $3,000 couple Includes Welcome Reception, 2 luncheons, Special VIP $1,500 single Reception, Friday and Saturday dinners with special seating, tickets for two optional tours and student underwriting. Blenheim Club Package (US Tax deduction: $940 couple /$360 single) $2,500 couple Includes Welcome Reception, 2 luncheons, Saturday Gala $1,250 single Dinner, tickets for two optional tours and student underwriting. Following are Individual Ticket Prices if Purchased Separately Basic Registration – Member $475.00

Basic Registration – Non-member (Includes one year membership)

$600.00

Special Teacher Registration – Teachers at secondary, high school or college level; includes all sessions and luncheons.

$100.00

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Friday Dinner and Reception (cash bar) $145.00 [__] Person(s) Saturday Black-tie Gala Dinner and Reception $195.00 [__] Person(s) National Cryptologic Museum Tour (Thursday) $90.00 [__] Person(s) Dodona Manor Tour (Thursday) $70.00 [__] Person(s) Washington By Night Tour (Thursday evening after reception) $40.00 [__] Person(s) Following are Single-Day Tickets for Locals Unable to Register for Whole Conference Thursday (Includes evening Welcome Reception) $75.00 [__] Person(s) Friday sessions (Includes Luncheon, but not dinner) $225.00 [__] Person(s) Saturday sessions (Includes Luncheon, but not dinner) $225.00 [__] Person(s)

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[__] Person(s) Early Bird Eligible

$________

[__] Person(s) Early Bird Eligible

$________

[__] Person(s) Early Bird Eligible [__] Person(s) Early Bird Eligible [__] Person(s)

$________ $________ $________ $________ $________ $________ $________ $________ $________ $________ $________

If received by July 1, 2013, deduct 10% from Registration Fee or Package Price Total Amount Due:

$________

For late registration (after October 1), please add $50 per registrant. Checks should be made payable to “The Churchill Centre” and sent with this form to the address below, _ or FAX or phone Visa/MasterCard/Discover/American Express information: Card Number: ________________________________________Exp. Date:____________________ CVS Code_________________________ Authorized Signature: _ ___________________________ Print name exactly as it appears on the card:_ _________________________________ If your credit card billing address is different from the address on top of registration form, please include billing address here:________________________ ____________________________________________________________________________________________________________ PLEASE NOTE: You may also register online by going to the secure server at http://bit.ly/14Hiaf1.

THE CHURCHILL CENTRE

P.O. Box 945, Downers Grove, IL 60515-0945 Toll Free: 888-WSC-1874 • Local Phone: 630-512-9341 • FAX: 630-515-1123 WWW.WINSTONCHURCHILL.ORG


Registration Form