Individual Registration

Please enter information in the form below to process registration for event ASIST (June 15-16).

First Name *

Last Name *

Organization

Mailing Address *

Address 2

City *

Province *

Postal code *

Email *

Comment

No refund will be issued for cancellations after registration cutoff date.  Cancellations prior to this will be fully refunded.

Coupon

Amount

Discount Amount

Gross amount

Payment Method

Credit Card

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*

Champlain East Branch
329 Pitt Street
Cornwall , K6J 3R1, Ontario
1-800-493-8271
office@cmha-east.on.ca
Hours:
Monday to Friday 8:30am – 4:30pm