WACE INSTITUTE TEAM REGISTRATION
  Primary Contact E-Mail Address:
  Institution Name:
  Institution Mailing Address:
   
  City:
  State / Province:
  Country:
  Postal Code:
  Telephone Number:
  Approximate Number of Team Members
     
     
  DOMESTIC Current Anticipated A priority for
planning at the Institute
         
  Internships
Priority for Planning
  Cooperative Education or Sandwich Placements
Priority for Planning
  Work-Integrated Learning Placements
Priority for Planning
  Work-Integrated Learning Simulations, & Other Non-placement WIL
Priority for Planning
  Service-Learning / Community Service
Priority for Planning
  Undergraduate Research
Priority for Planning
  Community-based Research
Priority for Planning
  Project / Problem-based Learning
Priority for Planning
  Other (Please Describe)
 
     
  INTERNATIONAL Current Anticipated A priority for
planning at the Institute
         
  Global Partnerships
Priority for Planning
  Study Abroad
Priority for Planning
  International SL / Community Service
Priority for Planning
  International Internships
Priority for Planning
  International Cooperative Education
Priority for Planning
  International WIL / Coop etc Exchanges
Priority for Planning
  Other (Please Describe)  
 
     
  Deposit Payment
 

A non-refundable registration deposit of $5,000 (first two registrants)
must accompany your Institute Registration Form no later than April 1, 2014.

Full payment must be received by May 15, 2014

   
  Deposit Payment Method
  ATTENTION: Payment by Credit Card REQUIRES ALL BILLING ADDRESS INFORMATION TO BE FILLED IN!
   
  Please Select Desired Form of Payment:
(See Instruction Below Regarding Payments)
     
  Credit Card Number (MasterCard or Visa Only):
  Expiration Date (mm/yyyy):
  Name on Card:
  Billing Address (if different from above):
   
  City:
  State / Province:
  Country:
  Postal Code:
     
 

World Association for Cooperative Education WACE
WACE Federal Tax ID # 04-3279172

If Paying by Check Send Registration Form and Payment to:
WACE
Suite 125
600 Suffolk Street
Lowell, MA 01854
USA
Attn: Marty Ford, Director of Global Partnerships & Programs

Please make checks payable to: WACE

For Bank Transfer, please contact the WACE Secretariat for our banking information at
Marty_Ford@uml.edu