National Culture of Peace/Canadian Peace Initiative Symposium 

NOVEMBER 21 - 23, 2004, at McMASTER UNIVERSITY IN HAMILTON, ONTARIO, CANADA

First name:__________________________________  Surname:__________________________________

Organization:____________________________________________________________________________

Address:________________________________________________________________________________

City:__________________________________  Prov./State:___________________  Postal code/Zip:______________

Phone:________________________________________  Fax:_____________________________________

Email:_________________________________________  Website:_________________________________

Dietary/Special Needs:_____________________________________________________________________

I wish to participate in the following (please check all that apply):
                                                                                                 Earlybird Fee           Registration                    Amount
Check
                         Event                                                     Prior to Oct. 31        After Nov. 1                    Payable
                                                                                                                                                                              $
_____ National Culture of Peace Program/CPI Symposium        Full:      $200           Full:       $250
           Sunday Nov. 21 to Tuesday Nov. 23                              Student:   25           Student:     50
                                                                                                   Retiree:    50           Retiree:      75                 _______


                                                                                                            
TOTAL PAYABLE:             $   _______


Payment Method:

_____ Cheque (made payable to Canadian Centres for Teaching Peace    _____  Money Order

_____ Visa     _____ Mastercard     Cardholder's Name________________________________

Card Number:_________________________________  Expiry Date:_____________________

Please mail or fax form with payment to:

Robert Stewart, Canadian Centres for Teaching Peace
Box 70, Okotoks, AB, Canada T1S 1A4
Tel: 1-403-938-5335        Fax: 1-403-938-4117

Cancellations are allowed up to November 10 with a 15% cancellation fee.  Though refunds are not possible for cancellations after November 10, registrants unable to attend can assign their participation to someone else.  All amounts above in Canadian dollars.  If paying in U.S. dollars, multiply by .8

Registration fees are intended to cover conference costs.  Any surplus will be contributed to the Canadian Peace Education Foundation (ref. http://www.peace.ca/foundation.htm )